An ophthalmological examination begins with collecting an anamnesis (general and special). For examination, the patient should be seated facing the light. First, the healthy eye is examined. During an external examination, the condition of the eyelids, the area of the lacrimal sac, the position of the eyeball, the width of the palpebral fissure, the condition of the conjunctiva, sclera, cornea, anterior chamber of the eye and the iris with the pupil visible within this fissure are determined. The conjunctiva of the lower eyelid and the lower transitional fold is examined by pulling the lower eyelid when the patient looks up. conjunctiva upper eyelid and the upper transitional fold are inspected by turning upper eyelid. To do this, when the patient is looking down, grab the ciliary edge of the upper eyelid with the thumb and forefinger of the right hand, pull it slightly down, moving it away from the eye at the same time; on top edge eyelid cartilage is placed with an edge thumb left hand (or an eye glass rod) and, pressing the cartilage downwards, turn the eyelid upward by the ciliary edge.
To examine the eyeball when the eyelids are swollen or severe, it is necessary, after preliminary instillation of a 0.5% dicaine solution, to move them apart using eyelid lifters inserted behind the upper and lower eyelids. When examining the lacrimal ducts, pressing a finger on the area of the lacrimal sac, the presence or absence of discharge from the lacrimal openings is noted. To examine the cornea, iris and anterior surface of the lens, use the lateral illumination method, focusing the light from a table lamp on the eye with a strong convex lens (+20 D). The changes are even more clearly visible when viewed through a binocular loupe (see). External examination of the eyes ends with the study of pupillary reflexes (see). Next, they examine (see), the fundus of the eye (see), visual functions (see,) and intraocular pressure (see).
Ophthalmological examination
The examination of the organ of vision must be carried out strictly according to plan. This plan should be based on the anatomical principle, i.e., anatomically sequential consideration of the individual parts of the organ of vision.
They start with a preliminary history, in which the patient outlines his complaints (pain, redness of the eye, dysfunction, etc.; a more detailed and targeted history - personal, family, hereditary - should, according to S.S. Golovin, be attributed to the end of the study). After this, they begin to study the anatomical state of the organ of vision: adnexa, anterior part of the eyeball, internal parts of the eye, then examine the functions of the eye and general state body.
In detail, the ophthalmological examination includes the following.
General information about the patient: gender, age, profession, place of residence. The patient's main complaint is his gait.
Inspection. General habitus, skull shape, face (asymmetry, condition of facial skin, one-sided graying of eyelashes, eyebrows, scalp hair, etc.).
The eye socket and its neighboring areas. Eyelids - shape, position, surface, mobility; palpebral fissure, eyelashes, eyebrows. Lacrimal organs - lacrimal glands, lacrimal openings, canaliculi, lacrimal sac, nasolacrimal canal. Connective membrane (conjunctiva) - color, transparency, thickness, surface, presence of scars, nature of the discharge. Position of the eyeball [exophthalmos, enophthalmos (see Exophthalmometry), displacement], size, mobility, intraocular pressure (see Ocular tonometry).
Sclera - surface, color. Cornea - shape, surface, transparency, sensitivity. Anterior chamber of the eye - depth, uniformity, chamber moisture. Iris - color, pattern, position, mobility. Pupils - position, size, shape, reactions. Lens - transparency, opacification (stationary, progressive, its degree), position of the lens (displacement, dislocation). Vitreous body - transparency, consistency, hemorrhages, liquefaction, foreign body, cysticercus. Fundus (see Ophthalmoscopy), disc optic nerve- size, shape, color, boundaries, course of blood vessels, level; periphery of the fundus - color, condition of blood vessels, presence of foci of hemorrhage, exudation, edema, pigmentation, primary and secondary retinal detachment, neoplasm, subretinal cysticercus; yellow spot- hemorrhage, degeneration, perforated defect, etc.
Special methods for studying the organ of vision - see Biomicroscopy, Gonioscopy, Diaphanoscopy of the eye, Ophthalmodynamometry, Ocular tonometry. An electromagnetic test (see Eye Magnets) makes it possible, using hand-held or stationary magnets, to determine the presence of magnetic fields in the eye or in the tissues surrounding it. foreign bodies.
X-ray diagnostics, which is widely used in ophthalmological examinations, can detect changes in the bones of the skull, orbit, its contents (tumors, etc.), foreign bodies in the eye and surrounding tissues, changes in the tear ducts, etc.
Study visual functions- see Campimetry, Visual acuity, Visual field.
Refraction of the eyes (see) is determined by subjective (selection of corrective glasses) and objective methods (see Skiascopy, Refractometry of the eye).
Accommodation - the position of the nearest point of view, the strength and width of accommodation are determined.
Color perception (see) - color recognition by central vision - is more often studied using the tables of E. B. Rabkin. Light perception - adaptation to light and darkness - is studied using adaptometers (see) and adaptoperimeters by S. V. Kravkov and N. A. Vishnevsky, A. I. Dashevsky, A. I. Bogoslovsky and A. V. Roslavtsev and etc. Eye movements - determination of the symmetrical position of the eyes, their mobility, fusion ability, binocular vision, latent and obvious strabismus, muscle paralysis and others movement disorders. Electroretinography (see) has known value in the diagnosis of certain eye diseases.
Communication with common diseases. Examination of the patient's body with the participation of relevant specialists. Laboratory research- microbiological, blood, urine, cerebrospinal fluid tests, Wasserman reaction, tuberculin tests; X-ray examinations, etc.
Compiled by: A.F. Belyanin
The proposed tasks will allow students to independently master the basic methods of researching eye diseases necessary for working on practical classes and at an outpatient appointment; complete documentation correctly.
Introduction
Mastering the practical skills of examining patients is the most important point in mastering any medical discipline. This is especially true for ophthalmology, since students are becoming familiar with many research methods for the first time.
The main practical skills that students must possess are the following:
external inspection method;
examination of the conjunctiva of the upper and lower eyelids;
side lighting method;
determining the sensitivity of the cornea;
identification of superficial defects of the cornea;
determination of peripheral vision (perimetry);
burying eye drops and laying ointments;
application of monocular and binocular dressings, application of cotton-gauze stickers;
examination of the eye in transmitted light;
skiascopy;
ophthalmoscopy;
determination of visual acuity;
determination of color perception;
determination of intraocular pressure;
determining the refraction of the eye by selecting spectacle lenses and the ability to record the obtained data;
determining the nearest point of clear vision;
determination of the strength of an unknown spectacle glass using the neutralization method;
determination of interpupillary distance;
ability to write a prescription for glasses.
Additionally, methods such as exophthalmometry, determining the strabismus angle according to Hirschberg, conducting a color nasolacrimal test, determining the volume of accommodation, refractometry, etc. can be mastered.
In the process of mastering diagnostic methods, each student records the examination results in his notebook. The notes are presented to the teacher at the end of the lesson.
Task No. 1: external examination, eversion of eyelids, color nasolacrimal test.
External examination is an important part of preliminary acquaintance with the pathology of the eye and its auxiliary apparatus. It does not require special devices and is usually carried out in natural light. External inspection is carried out in a certain sequence.
Pay attention to the skin of the eyelids: the presence or absence of edema, hyperemia, local or diffuse infiltrates, subcutaneous hematoma and emphysema (sensation of crepitus), superficial neoplasms. Normal: the skin of the eyelids is not changed.
The position of the eyeballs is determined (position of the visual axes, eye mobility, uniformity of both eyes, their displacement to the sides). In this case, deviation of the eyes may be observed more often in the horizontal meridians (convergent and divergent strabismus), limitation of eye mobility in a certain direction, unilateral or bilateral protrusion of the eye forward (exophthalmos). Instrumental methods Their more precise research will be covered in the next assignment. In the presence of exophthalmos or displacement of the eyeball to the sides, the accessible zones of the orbit are palpated along the entire circumference (this may reveal compactions and defects in the bony edge of the orbit). The degree of compression of the orbital tissues by the eyeball (eye reposition) is also determined. All this can be easily checked on each other: by pressing on the eyeball with the eyelids closed, you can feel how freely it moves deeper into the orbit. In the presence of a tumor in the orbit, eye reposition is difficult; with endocrine exophthalmos, it may not be disturbed. Normal: the position of the eyeballs in the orbit is correct, movements are not fully limited.
Next, the condition of the eyelids and the width of the palpebral fissures are examined. Normally, the width of the palpebral fissure on both sides is the same and averages 6–10 mm in the center and 3–4 mm in the area of the inner and outer edges of the eyelids, the length of the palpebral fissure is about 30 mm (these parameters must be measured on each other). With a calm look straight ahead, the upper eyelid slightly covers the upper segment of the cornea, the lower eyelid does not reach the limbus by 1 - 2 mm. One or two-sided narrowing of the palpebral fissure, accompanied by redness of the eye (photophobia, lacrimation), is evidence of inflammation of the eyeball or damage to its surface membranes (conjunctiva, cornea). A narrowing of the palpebral fissure, without any reaction from the eye, can be the result of congenital or acquired ptosis. In this case, the upper eyelid may partially or completely cover the pupil and opens only when the frontalis muscle is tense. Normally, when the eyelids close, the ciliary edges are tightly adjacent to each other. In some cases due to paresis or paralysis facial nerve, with cicatricial deformities and shortening of the eyelids, tight closure does not occur (lagophthalmos). Normal: the width of the palpebral fissures is without pathology.
The position of the edges of the eyelids is noted. Normally, the edges of the eyelids fit tightly to the eyeball. With pathology, the edge of the eyelid may move away from the eyeball (eversion of the eyelid edge) and turn inward (entropion).
The position of the eyelashes is noted (there may be abnormal eyelash growth - trichiasis), the condition and width of the intermarginal space (normally it is 1.5 - 2 mm), the condition and position of the lacrimal openings. They are located at the inner edge of both eyelids on a small protrusion (the lacrimal papilla) and, as a rule, are turned towards the eyeball in the area of the lacrimal lake in the inner corner of the eye. They are visible in the form of dots when the inner corner of the eyelids is slightly pulled back. With pathology, there may be an anterior displacement of the lacrimal puncta (eversion), narrowing, absence (atresia), or several lacrimal puncta. If there is a pathology of lacrimation and the patient complains of lacrimation, lacrimation can be seen, i.e. fluid level along the lower edge of the eyelid. In this case, you should always check the condition of the lacrimal sac by pressing on the place of its projection in the area of the inner corner of the eyelids. With chronic purulent inflammation of the lacrimal sac (purulent dacryocystitis), you can see how mucous or purulent discharge is released from the points.
The conjunctiva of the upper and lower eyelids is examined. The lower eyelid turns out easily, just pull it down and ask the patient to look up. Eversion of the upper eyelid requires skill. The technique is as follows (the picture can be seen in the textbook of eye diseases edited by T.I. Eroshevsky): the patient is asked to look down, the upper eyelid is pulled up with the thumb of the left hand, the ciliary edge of the eyelid is grabbed with the thumb and forefinger of the right hand and slightly pulled away from the eyelid apple downwards and then, pressing the thumb of the left hand on the upper edge of the cartilage, with the right hand the edge of the eyelid is turned upward. At the same time, it is turned out, the thumb of the left hand is removed from under the eyelid and they are used to hold the eyelid by the ciliary edge in an inverted state and examine it along its entire length. You can use a glass rod rather than the thumb of your left hand as a lever.
Normally, the conjunctiva of the eyelids and eyeball is smooth, transparent, thin, moist, through it deep vessels and meibomian glands are clearly visible, located in the thickness of the cartilage in the form of yellowish-gray stripes perpendicular to the edge of the eyelid. With inflammation, the conjunctiva becomes thickened, swollen, folded, diffuse hyperemia appears, it may contain deep and superficial follicles, mucus, pus, and viscous threads of secretion.
Normally, the eyeball is white and calm, with white sclera visible through the transparent conjunctiva. When the eye is inflamed, hyperemia is observed; it can be superficial (conjunctival) and deep (pericorneal). Conjunctival hyperemia is characterized by a bright red color, a large number of dilated blood-filled vessels, decreasing towards the cornea and increasing towards the fornix. With a pericorneal injection, characteristic of inflammation of the eyeball itself, a diffuse deep injection from bright red to bluish-violet color is noted, localized directly near the cornea in the limbus area along its entire circumference or in a separate sector.
In conclusion, it is necessary to check the functional state of the lacrimal ducts on each other (colored nasolacrimal test). One drop of a 2% collargol solution is instilled into the conjunctival cavity (the patient should not squeeze the eyelids, so the lower and upper eyelids are lightly held with fingers after instillation). With normal patency of the lacrimal apparatus, after 1–2 minutes the paint completely disappears from the conjunctival cavity and the eyeball becomes discolored. If tear drainage is impaired, a strip of colored liquid along the edge of the lower eyelid remains for a long time. The final result of this test is assessed after 5 - 10 minutes by the appearance of paint in the nose (when blowing your nose), but in this case you don’t have to do this. As a rule, rapid absorption of paint from the conjunctival cavity indicates good lacrimal drainage function.
Vision diagnostics is an important step in prevention eye diseases and maintaining good vision long years! Timely detection of ophthalmological pathology is the key to successful treatment of many eye diseases. As our practice shows, the occurrence of eye diseases is possible at any age, so everyone needs to undergo a high-quality ophthalmological examination at least once a year.
Why is a complete vision diagnostic necessary?
Vision diagnostics is necessary not only to identify primary ophthalmological pathology, but also to resolve the issue of the possibility and advisability of performing a particular operation, choosing patient treatment tactics, as well as accurately diagnosing the condition of the organ of vision in a dynamic aspect. In our clinic, a complete ophthalmological examination is carried out using the most modern diagnostic equipment.
Cost of vision diagnostics
The cost of a diagnostic examination (vision diagnostics) depends on its volume. For the convenience of patients, we have created complexes in accordance with common eye diseases, such as cataracts, glaucoma, myopia, farsightedness, and fundus pathology.
| Service code | Service name | Qty services |
Price |
|---|---|---|---|
| A02.26.004 | Visometry, 2 eyes Code: A02.26.004 |
1 | 350 ₽ |
| A02.26.013 | Code: A02.26.013 |
1 | 550 ₽ |
| A02.26.015 | Ophthalmotonometry, 2 eyes Code: A02.26.015 |
1 | 300 ₽ |
| А03.26.001 | Biomicroscopy, 2 eyes Code: A03.26.001 |
1 | 900 ₽ |
| А03.26.018 | Code: A03.26.018 |
1 | 700 ₽ |
| A12.26.016 | Code: A12.26.016 |
1 | 350 ₽ |
| B01.029.001.009 | Code: B01.029.001.009 |
1 | 700 ₽ |
| Service code | Service name | Qty services |
Price |
|---|---|---|---|
| A02.26.004 | Visometry, 2 eyes Code: A02.26.004 |
1 | 350 ₽ |
| A02.26.013 | Determination of refraction using a set of trial lenses, 2 eyes Code: A02.26.013 |
1 | 550 ₽ |
| A02.26.015 | Ophthalmotonometry, 2 eyes Code: A02.26.015 |
1 | 300 ₽ |
| А03.26.001 | Biomicroscopy, 2 eyes Code: A03.26.001 |
1 | 900 ₽ |
| A03.26.003.001 | Code: A03.26.003.001 |
1 | 1,950 RUR |
| А03.26.018 | Biomicroscopy of the fundus (central zone), 2 eyes Code: A03.26.018 |
1 | 700 ₽ |
| A12.26.016 | Autorefractometry with a narrow pupil, 2 eyes Code: A12.26.016 |
1 | 350 ₽ |
| B01.029.001.009 | Consultation with an ophthalmologist Code: B01.029.001.009 |
1 | 700 ₽ |
| Service code | Service name | Qty services |
Price |
|---|---|---|---|
| B01.029.001.009 | Consultation with an ophthalmologist Code: B01.029.001.009 |
1 | 700 ₽ |
| В01.029.001.010 | Consultation with an ophthalmologist (surgeon) Code: B01.029.001.010 |
1 | 1,700 ₽ |
| В01.029.001.011 | Consultation with an anesthesiologist Code: B01.029.001.011 |
1 | 1,000 ₽ |
| В01.029.001.012 | Consultation with an ophthalmologist (vitreoretinologist) Code: B01.029.001.012 |
1 | 1 100 ₽ |
| B01.029.001.013 | Consultation with a candidate of medical sciences Code: B01.029.001.013 |
1 | 2,200 ₽ |
| B01.029.001.014 | Consultation with a doctor of medical sciences Code: B01.029.001.014 |
1 | 2,750 RUR |
| B01.029.001.015 | Professor consultation Code: B01.029.001.015 |
1 | 3,300 ₽ |
| В01.029.001.016 | Consultation with Professor, Doctor of Medical Sciences V.V. Kurenkov Code: B01.029.001.016 |
1 | 5 500 ₽ |
| Service code | Service name | Qty services |
Price |
|---|---|---|---|
| A02.26.004 | Visometry, 2 eyes Code: A02.26.004 |
1 | 350 ₽ |
| A02.26.009 | Color perception study, 2 eyes Code: A02.26.009 |
1 | 200 ₽ |
| A02.26.010 | Strabismus angle measurement, 2 eyes Code: A02.26.010 |
1 | 450 ₽ |
| A02.26.013 | Determination of refraction using a set of trial lenses, 2 eyes Code: A02.26.013 |
1 | 550 ₽ |
| A02.26.013.001 | Determination of refraction using a set of trial lenses in conditions of cycloplegia, 2 eyes Code: A02.26.013.001 |
1 | 800 ₽ |
| A02.26.015 | Ophthalmotonometry, 2 eyes Code: A02.26.015 |
1 | 300 ₽ |
| A02.26.015.001 | Ophthalmotonometry (iCare device), 2 eyes Code: A02.26.015.001 |
1 | 650 ₽ |
| A02.26.015.002 | Daily tonometry using an iCare expert tonometer (1 day) Code: A02.26.015.002 |
1 | 1,850 RUR |
| A02.26.015.003 | Ophthalmotonometry (IOP according to Maklakov), 2 eyes Code: A02.26.015.003 |
1 | 450 ₽ |
| A02.26.020 | Schirmer test Code: A02.26.020 |
1 | 600 ₽ |
| A02.26.023 | Accommodation study, 2 eyes Code: A02.26.023 |
1 | 350 ₽ |
| A02.26.024 | Determination of the nature of vision, heterophoria, 2 eyes Code: A02.26.024 |
1 | 800 ₽ |
| А03.26.001 | Biomicroscopy, 2 eyes Code: A03.26.001 |
1 | 900 ₽ |
| A03.26.012 | Examination of the posterior corneal epithelium, 2 eyes Code: A03.26.012 |
1 | 600 ₽ |
| A03.26.002 | Gonioscopy, 2 eyes Code: A03.26.002 |
1 | 850 ₽ |
| A03.26.003 | Examination of the periphery of the fundus using a three-mirror Goldmann lens, 2 eyes Code: A03.26.003 |
1 | 1,950 RUR |
| A03.26.003.001 | Examination of the periphery of the fundus using a lens, 2 eyes Code: A03.26.003.001 |
1 | 1,950 RUR |
| A03.26.011 | Keratopachymetry, 2 eyes Code: A03.26.011 |
1 | 800 ₽ |
| A03.26.005 | Biomicrograph of the eye and its adnexa, 1 eye Code: A03.26.005 |
1 | 800 ₽ |
| A03.26.005.001 | Biomicrography of the fundus using a fundus camera, 2 eyes Code: A03.26.005.001 |
1 | 1 600 ₽ |
| А03.26.018 | Biomicroscopy of the fundus (central zone), 2 eyes Code: A03.26.018 |
1 | 700 ₽ |
| A03.26.019 | Optical examination of the retina using a computer analyzer (one eye), 1 eye Code: A03.26.019 |
1 | 1,650 RUR |
| А03.26.019.001 | Optical examination of the anterior part of the eye using a computer analyzer (one eye), 1 eye Code: A03.26.019.001 |
1 | 1 200 ₽ |
| А03.26.019.002 | Optical examination of the posterior part of the eye using a computer analyzer in angiography mode (one eye), 1 eye Code: A03.26.019.002 |
1 | 2 500 ₽ |
| A03.26.019.003 | Optical examination of the optic nerve head and nerve fiber layer using a computer analyzer, 1 eye Code: A03.26.019.003 |
1 | 2,000 ₽ |
| А03.26.019.004 | Optical examination of the posterior segment of the eye (optic nerve) using a computer analyzer, 1 eye Code: A03.26.019.004 |
1 | 3 100 ₽ |
| A03.26.020 | Computer perimetry (screening), 2 eyes Code: A03.26.020 |
1 | 1 200 ₽ |
| A03.26.020.001 | Computer perimetry (screening + thresholds), 2 eyes Code: A03.26.020.001 |
1 | 1,850 RUR |
| A04.26.002 | Ultrasound examination of the eyeball (B-scan), 2 eyes Code: A04.26.002 |
1 | 1 200 ₽ |
| A04.26.004.001 | Ultrasound biometry of the eye (A-method), 2 eyes Code: A04.26.004.001 |
1 | 900 ₽ |
| A04.26.004.002 | Ultrasound biometry of the eye with calculation of IOL optical power, 2 eyes Code: A04.26.004.002 |
1 | 900 ₽ |
| A05.26.007 | Optical biometrics of the eye, 2 eyes Code: A05.26.007 |
1 | 650 ₽ |
| A12.26.007 | Load-unload tests to study the regulation of intraocular pressure, 2 eyes Code: A12.26.007 |
1 | 400 ₽ |
| A12.26.016 | Autorefractometry with a narrow pupil, 2 eyes Code: A12.26.016 |
1 | 350 ₽ |
| A12.26.018 | Videokeratotopography, 2 eyes Code: A12.26.018 |
1 | 1 200 ₽ |
| A23.26.001 | Selection of spectacle vision correction, 2 eyes Code: A23.26.001 |
1 | 1 100 ₽ |
| A23.26.001.001 | Selection of spectacle vision correction (with cycloplegia) Code: A23.26.001.001 |
1 | 1,550 RUR |
| A23.26.001.002 | Selection of spectacle vision correction (during a comprehensive examination) Code: A23.26.001.002 |
1 | 650 ₽ |
| A23.26.001.003 | Selection of spectacle vision correction (with cycloplegia during a comprehensive examination) Code: A23.26.001.003 |
1 | 850 ₽ |
| A25.26.001 | Purpose medicines for diseases of the organ of vision Code: A25.26.001 |
1 | 900 ₽ |
| B01.029.002 | Repeated appointment (examination, consultation) with an ophthalmologist Code: B01.029.002 |
1 | 850 ₽ |
| DU-OFT-004 | Training in using SCL Code: DU-OFT-004 |
1 | 1 500 ₽ |
| DU-OFT-005 | Determining your dominant eye Code: DU-OFT-005 |
1 | 400 ₽ |
What tests are included in a complete diagnostic examination of the visual system and what are they?
Any ophthalmological examination begins, first of all, with a conversation, identifying the patient’s complaints and collecting an anamnesis. And only after this they move on to hardware methods for studying the organ of vision. The hardware diagnostic examination includes determining visual acuity, studying the patient’s refraction, measuring intraocular pressure, examining the eye under a microscope (biomicroscopy), pachymetry (measuring the thickness of the cornea), echobiometry (determining the length of the eye), ultrasonography eyes (B-scan), computer keratotopography and careful (fundus) with a wide pupil, determination of the level of tear production, assessment of the patient’s field of vision. When ophthalmological pathology is detected, the scope of the examination is expanded for a specific study clinical manifestations for a specific patient. Our clinic is equipped with modern, highly professional ophthalmological equipment from companies such as ALCON, Bausch & Lomb, NIDEK, Zeiss, Rodenstock, Oculus, which allows us to conduct studies of any level of complexity.
In our clinic, special tables with pictures, letters or other signs are used to determine the patient’s visual acuity and refraction. Using an automatic phoropter NIDEK RT-2100 (Japan), the doctor, alternately changing diopter glasses, selects the most optimal lenses that provide best vision for the patient. In our clinic, we use NIDEK SCP - 670 halogen sign projectors with 26 test patterns and analyze the results obtained under narrow and wide pupil conditions. Computer refraction research is carried out on a NIDEK ARK-710A autorefractive meter (Japan), which allows you to most accurately determine the refraction of the eye and the biometric parameters of the cornea.
Intraocular pressure measured using a non-contact tonometer NIDEK NT-2000. If necessary, measurement of intraocular pressure is carried out by contact method - Maklakov or Goldman tonometers.
To examine the condition of the anterior segment of the eye (eyelids, eyelashes, conjunctiva, cornea, iris, lens, etc.), a NIDEK SL-1800 slit lamp (biomicroscope) is used. On it, the doctor evaluates the condition of the cornea, as well as deeper structures such as the lens and vitreous.
All patients undergoing a complete ophthalmological examination mandatory The fundus of the eye is examined, including areas of its extreme periphery, under conditions of maximum pupil dilation. This makes it possible to identify dystrophic changes in the retina, diagnose its breaks and subclinical detachments - a pathology that is not clinically determined by the patient, but requires compulsory treatment. To dilate the pupils (mydriasis), drugs are used to quickly and short acting(Midrum, Midriacil, Cyclomed). If changes are detected in the retina, we prescribe preventive laser coagulation using a special laser. Our clinic uses the best and most modern models: YAG laser, diode laser NIDEK DC-3000.
One of the important methods for diagnosing a patient’s vision before any refractive surgery for vision correction is computer topography of the cornea, aimed at examining the surface of the cornea and its pachymetry - measuring its thickness.
One of the anatomical manifestations of refractive error (myopia,) is a change in the length of the eye. This is one of the most important indicators, which in our clinic is determined by a non-contact method using the IOL MASTER device from ZEISS (Germany). This is a combined biometric device, the research results of which are also important for calculating IOLs for cataracts. Using this device, during one session, the length of the eye axis, the radius of curvature of the cornea and the depth of the anterior chamber of the eye are measured immediately one after another. All measurements are carried out using a non-contact method, which is extremely comfortable for the patient. Based on the measured values, the built-in computer can suggest optimal intraocular lenses. The basis for this is the current international calculation formulas.
Ultrasound examination is an important addition to generally accepted clinical methods ophthalmological diagnostics, this is a widely known and informative instrumental method. This study makes it possible to obtain information about the topography and structure of normal and pathological changes in the tissues of the eye and orbit. Using the A-method (one-dimensional imaging system), the thickness of the cornea, the depth of the anterior chamber, the thickness of the lens and inner membranes of the eye, as well as the length of the eye are measured. The B-method (two-dimensional imaging system) allows you to assess the condition of the vitreous body, diagnose and evaluate the height and extent of choroidal and retinal detachment, identify and determine the size and localization of ocular and retrobulbar neoplasms, as well as detect and determine the location of a foreign body in the eye.
Visual field examination
Another necessary method for diagnosing vision is visual field testing. The purpose of determining the field of view (perimetry) is:
- diagnosis of eye diseases, in particular glaucoma
- dynamic observation to prevent the development of eye diseases.
Also, using hardware techniques, it is possible to measure the contrast and threshold sensitivity of the retina. These studies provide the possibility of early diagnosis and treatment of a number of eye diseases.
In addition, other parametric and functional data of the patient are examined, for example, determining the level of tear production. The most diagnostically sensitive ones are used functional studies- Schirmer test, Norn test.
Optical tomography of the retina
Another modern method for studying the inner lining of the eye is. This unique technique allows you to get an idea of the structure of the retina throughout its entire depth, and even measure the thickness of its individual layers. With its help, it became possible to detect the earliest and smallest changes in the structure of the retina and optic nerve, which are not accessible to the resolving abilities of the human eye.
The operating principle of an optical tomograph is based on the phenomenon of light interference, which means that the patient is not exposed to any harmful radiation during the study. The examination takes a few minutes, does not cause visual fatigue and does not require direct contact of the device’s sensor with the eye. Similar devices for vision diagnostics are available only in large clinics in Russia, Western Europe and the USA. The study provides valuable diagnostic information about the structure of the retina in diabetic macular edema and allows you to accurately formulate a diagnosis in difficult cases, as well as gain a unique opportunity to observe the dynamics of treatment based not on the subjective impression of the doctor, but on clearly defined digital values of retinal thickness.
The study provides comprehensive information about the condition of the optic nerve and the thickness of the layer of nerve fibers around it. High-precision measurement of the latter parameter guarantees the identification of the earliest signs of this terrible disease, even before the patient notices the first symptoms. Considering the ease of implementation and the absence of unpleasant sensations during the examination, we recommend repeating control examinations on the scanner for glaucoma every 2-3 months, for diseases of the central zone of the retina - every 5-6 months.
Repeated examination allows you to determine the activity of the pathology, clarify the correctness of the chosen treatment, and also correctly inform the patient about the prognosis of the disease, which is especially important for patients suffering from macular holes, since the likelihood of a similar process developing in a healthy eye can be predicted after a tomograph study. Early, “preclinical” diagnosis of fundus changes in diabetes mellitus is also possible with this amazing device.
What happens after hardware research is completed?
After completing hardware tests (vision diagnostics), the doctor carefully analyzes and interprets all the information received about the condition of the patient’s organ of vision and, based on the data obtained, makes a diagnosis, on the basis of which a treatment plan for the patient is drawn up. All research results and treatment plan are explained to the patient in detail.
22.01.2016 | Viewed by: 5,238 people.Regular examination is the best prevention of eye diseases. Diagnosis of such diseases can only be carried out by an experienced ophthalmologist in a specialized equipped office. It is important that the ophthalmologist identifies the first signs of abnormalities in time. Successful treatment largely depends on the speed of their detection at the stage of reversible changes.
One examination by a doctor and a subsequent conversation with him is not enough. It is necessary to carry out additional specific examination methods using modern equipment to clarify the diagnosis and prescribe treatment. The doctor should tell you in detail about the accurate diagnosis and determination of visual acuity, as well as possible deviations and pathologies.
Ultra-modern diagnostic methods help establish a highly accurate diagnosis and allow highly effective control of treatment. Here are the most common methods for diagnosing the most common eye diseases.
A doctor's examination reveals abnormalities using the following painless procedures:
A procedure that allows the ophthalmologist to see parts of the fundus on the surface of the eye. This method remains one of the most significant and popular in diagnosing eye diseases. The non-contact method is performed using a lens or a special ophthalmoscope device.
Allows you to evaluate when preventive examinations the main function is visual acuity for distance. Decreased vision is an important signal in diagnosing diseases. The examination is first carried out without correction - the patient, closing one eye at a time, names the letters on the table indicated by the ophthalmologist. If there are violations, the procedure is performed with correction using specialized frames and lenses.
This method determines the optical power of the eye and diagnoses refractive errors and vision defects: myopia, farsightedness, astigmatism. Now the procedure has begun to be carried out using refractometers, which allows the patient not to waste a lot of time and facilitates the eye doctor’s manipulations.
The study is recommended for people over 40 years of age, as they have increased risk development of glaucoma. The procedure measures intraocular pressure, which is carried out in the following ways: by palpation, according to Maklakov (using weights) with a pneumotonometer and others.
An important method for determining the presence of peripheral vision and diagnosing pathological diseases - glaucoma and the process of destruction of the optic nerve. The study is carried out using specialized hemispherical electrical devices on which light spots are displayed.
Vision test for color perception
Widespread and intended to determine violations of color sensitivity thresholds - color blindness. The inspection is carried out using Rabkin's polychromatic tables.
The procedure for microscopic examination of the ocular segment using a special device - a slit lamp. With significant magnification, the ophthalmologist can clearly see the tissues of the eye - the cornea and conjunctiva, as well as the lens, iris, and vitreous body.
Determines the degree of astigmatism of the anterior surface and the refractive power of the cornea. The radius of refraction is measured with an ophthalmometer.
Grishberg's simple method allows you to determine the angle of strabismus using an ophthalmoscope through which the patient is looking. The ophthalmologist determines the problem by observing the reflection of light on the corneal surface.
It is carried out in case of obstruction of the lacrimal canaliculi. IN tear ducts Thin tubes (cannulas) with a syringe and solution are inserted. If the patency is normal, then the liquid from the syringe will penetrate into the nasopharynx. If there is an obstruction, the solution will not pass through and will spill out.
Usually performed in infants and older people medicinal purposes, since they may experience stenosis of the lacrimal openings. Bougienage is carried out using expanding probes using local anesthesia.
To determine the diagnosis of common ailments, such as conjunctivitis, myopia, cataracts, such diagnostic methods are usually sufficient. However, if the eye doctor doubts the diagnosis, then additional ways examination of diseases using specialized equipment carried out in optometric centers.Additional methods in eye diagnostics
Ultrasound is a popular research tool due to the receipt of accurate and complete information and the high effectiveness of the procedure. Ultrasound examination is necessary to detect eye abnormalities, tumors, and retinal detachment.
The method determines the central field of vision for colors and is used to detect diseases of the optic nerve, glaucoma and retina. The diagnostic kampimeter consists of a special large screen, where the patient looks with each eye alternately through a slit on a black screen.
The electrophysiological research method has found wide application in the study of the cerebral cortex, retina and levels of damage to the optic nerve, and the function of the nervous department of the optical apparatus.
A method that examines the surface of the cornea before laser correction. It is carried out on an automated computer system by scanning to determine the sphericity of the surface.
Dynamic study of intraocular pressure. IOP takes about 5 minutes, in such a short period of time you can get important information about the state of fluid outflow inside the eye.
The method allows you to accurately determine the thickness of the cornea; it is necessarily prescribed for laser operations
Shows the condition of the fundus and retinal vessels. A series of high-precision images are taken after the fluorescent solution is administered intravenously.
Contactless modern method OCT is used to determine the condition of the optic nerve and retina.
Operational examination under an optical device to detect ticks.
A procedure that determines tear production. The test is performed for symptoms of dry eye. An ophthalmological test is placed on the edge of the patient's lower eyelid, which can be used to determine if it is wet with tears.
Way precise definition glaucoma using a lens. The angle of the anterior chamber is examined.
Used for retinal dystrophy and detachment, as well as to obtain data about its peripheral parts, not detected during classical examination.
High-precision modern instruments and a variety of techniques allow you to conduct research accurately and efficiently visual organs at the cellular level. Most diagnostics are carried out non-contact and painlessly, without requiring prior preparation of the patient. In the relevant sections you can learn in detail about the methods for diagnosing eye diseases.
■ Patient complaints
■ Clinical examination
External examination and palpation
Ophthalmoscopy
■ Instrumental examination methods
Biomicroscopy Gonioscopy
Echoophthalmography
Entoptometry
Fluorescein angiography of the retina
■ Examination of the organ of vision in children
PATIENT'S COMPLAINTS
With diseases of the organ of vision, patients complain of:
Decreased or changed vision;
Pain or discomfort in the eyeball and surrounding areas;
lacrimation;
External changes in the condition of the eyeball itself or its appendages.
Visual impairment
Decreased visual acuity
It is necessary to find out what visual acuity the patient had before the illness; whether the patient discovered decreased vision by chance or can he accurately indicate under what circumstances this occurred; sn-
whether vision decreased gradually or whether its deterioration occurred quite quickly in one or both eyes.
Three groups of reasons can be distinguished that lead to a decrease in visual acuity: refractive errors, clouding of the optical media of the eyeball (cornea, anterior chamber moisture, lens and vitreous body), as well as diseases of the neurosensory apparatus (retina, pathways and cortical section visual analyzer).
Vision changes
Metamorphopsia, macropsia And micropsies concern patients in case of localization of pathological processes in the macular area. Metamorphopsia is characterized by distortion of the shapes and outlines of objects, curvature of straight lines. With micro- and macropsia, the observed object appears to be either smaller or larger in size than it actually exists.
Diplopia(double vision) can only occur when fixating an object with both eyes, and is caused by a violation of the synchronization of eye movements and the inability to project an image onto the central fovea of both eyes, as occurs normally. When one eye is closed, diplopia disappears. Causes: disruption of the innervation of the external muscles of the eye or uneven displacement of the eyeball due to the presence of a space-occupying formation in the orbit.
Hemeralopia accompanies diseases such as hypovitaminosis A, retinitis pigmentosa, siderosis and some others.
Photophobia(photophobia) indicates inflammatory diseases or injury to the anterior segment of the eye. In this case, the patient tries to turn away from the light source or close the affected eye.
Glare(glare) - severe visual discomfort when bright light enters the eyes. It is observed with some cataracts, aphakia, albinism, cicatricial changes in the cornea, especially after radial keratotomy.
Seeing halos or rainbow circles around the light source occurs due to swelling of the cornea (for example, during a microattack of angle-closure glaucoma).
Photopsias- seeing flashes and lightning in the eye. Causes: vitreoretinal traction with incipient retinal detachment or short-term spasms of retinal vessels. Also photo
psia occur when the primary cortical centers of vision are affected (for example, by tumor).
The appearance of "flying flies" caused by the projection of the shadow of vitreous opacities onto the retina. They are perceived by the patient as points or lines that move along with the movement of the eyeball and continue to move after it stops. These “floaters” are especially characteristic of the destruction of the vitreous body in the elderly and patients with myopia.
Pain and discomfort
Unpleasant sensations in diseases of the organ of vision can be of a different nature (from a burning sensation to severe pain) and localized in the eyelid area, in the eyeball itself, around the eye in the orbit, and also manifest itself as a headache.
Pain in the eye indicates inflammatory processes in the anterior segment of the eyeball.
Unpleasant sensations in the eyelid area are observed in diseases such as stye and blepharitis.
Pain around the eye in the orbit occurs with lesions of the conjunctiva, injuries and inflammatory processes in the orbit.
Headache on the side of the affected eye is observed when acute attack glaucoma.
Asthenopia- discomfort in the eyeballs and orbits, accompanied by pain in the forehead, eyebrows, back of the head, and sometimes even nausea and vomiting. This condition develops as a result of prolonged work with objects located near the eye, especially in the presence of ametropia.
Tearing
Lacrimation occurs in cases of mechanical or chemical irritation of the conjunctiva, as well as with increased sensitivity of the anterior segment of the eye. Persistent lacrimation may result from increased tear production, impaired tear evacuation, or a combination of both mechanisms. Strengthening the secretory function of the lacrimal gland is reflexive in nature and occurs when the facial, trigeminal or cervical sympathetic nerve is irritated (for example, with conjunctivitis, blepharitis, and some hormonal diseases). A more common cause of lacrimation is impaired evacuation.
ation of tears along the lacrimal ducts due to pathology of the lacrimal openings, lacrimal canaliculi, lacrimal sac and nasolacrimal duct.
CLINICAL EXAMINATION
The examination always begins with the healthy eye, and in the absence of complaints (for example, during a preventive examination) - with the right eye. An examination of the organ of vision, regardless of the patient’s complaints and the doctor’s first impression, must be carried out consistently, according to the anatomical principle. An eye examination begins after a vision test, since after diagnostic tests it may worsen for a while.
External examination and palpation
The purpose of the external examination is to assess the condition of the orbital margin, eyelids, lacrimal organs and conjunctiva, as well as the position of the eyeball in the orbit and its mobility. The patient is seated facing the light source. The doctor sits opposite the patient.
First, inspect the areas of the eyebrows, the bridge of the nose, upper jaw, zygomatic and temporal bones, the area where the pre-auricular lymph nodes are located. The condition of these lymph nodes and the edges of the orbit is assessed by palpation. Sensitivity is checked at the exit points of the branches of the trigeminal nerve, for which a point located on the border of the inner and middle third of the upper edge of the orbit is simultaneously palpated on both sides, and then a point located 4 mm below the middle of the lower edge of the orbit.
Eyelids
When examining the eyelids, you should pay attention to their position, mobility, condition skin, eyelashes, anterior and posterior ribs, intercostal space, lacrimal openings and excretory ducts of the meibomian glands.
Skin of the eyelidsNormally, it is thin, tender, with loose subcutaneous tissue located underneath it, as a result of which swelling easily develops in the eyelid area:
At common diseases(kidney and cardiovascular diseases) and allergic angioedema, the process is bilateral, the skin of the eyelids is pale;
In inflammatory processes of the eyelid or conjunctiva, the swelling is usually one-sided, the skin of the eyelids is hyperemic.
The edges of the eyelids. Hyperemia of the ciliary edge of the eyelids is observed during the inflammatory process (blepharitis). Also, the edges may be covered with scales or crusts, after removal of which bleeding ulcers are found. Reduction or even baldness (madarosis) of the eyelid, abnormal growth of eyelashes (trichiasis) indicate chronic inflammatory process or a previous disease of the eyelids and conjunctiva.
Palpebral fissure. Normally, the length of the palpebral fissure is 30-35 mm, width 8-15 mm, the upper eyelid covers the cornea by 1-2 mm, the edge of the lower eyelid does not reach the limbus by 0.5-1 mm. Due to disturbances in the structure or position of the eyelids, the following pathological conditions arise:
Lagophthalmos, or “hare's eye”, is non-closure of the eyelids and gaping of the palpebral fissure with paralysis of the orbicularis oculi muscle (for example, with damage to the facial nerve);
Ptosis is a drooping of the upper eyelid that occurs when the oculomotor or cervical sympathetic nerve is damaged (as part of Bernard-Horner syndrome);
A wide palpebral fissure is characteristic of irritation of the cervical sympathetic nerve and Graves' disease;
Narrowing of the palpebral fissure (spastic blepharospasm) occurs due to inflammation of the conjunctiva and cornea;
Entropion is an inversion of the eyelid, usually the lower one, which can be senile, paralytic, cicatricial and spastic;
Ectropion - inversion of the eyelid, can be senile, cicatricial and spastic;
Coloboma of the eyelids is a congenital defect of the eyelids in the form of a triangle.
Conjunctiva
When the palpebral fissure is open, only part of the conjunctiva of the eyeball is visible. The conjunctiva of the lower eyelid, the lower transitional fold and the lower half of the eyeball is examined with the edge of the eyelid pulled down and the patient's gaze fixed upward. To examine the conjunctiva of the upper transitional fold and the upper eyelid, it is necessary to evert the latter. To do this, ask the subject to look down. The doctor, with the thumb and forefinger of his right hand, fixes the eyelid by the edge and pulls it down and forward, and then
index finger with his left hand he moves the upper edge of the cartilage down (Fig. 4.1).
Rice. 4.1.Stages of upper eyelid eversion
Normally, the conjunctiva of the eyelids and transitional folds pale pink, smooth, shiny, blood vessels are visible through it. The conjunctiva of the eyeball is transparent. There should be no discharge in the conjunctival cavity.
Redness (injection) the eyeball develops with inflammatory diseases organ of vision due to dilation of the vessels of the conjunctiva and sclera. There are three types of injection of the eyeball (Table 4.1, Fig. 4.2): superficial (conjunctival), deep (pericorneal) and mixed.
Table 4.1.Distinctive features of superficial and deep injection of the eyeball
Rice. 4.2.Types of injections of the eyeball and types of vascularization of the cornea: 1 - superficial (conjunctival) injection; 2 - deep (pericorneal) injection; 3 - mixed injection; 4 - superficial vascularization of the cornea; 5 - deep vascularization of the cornea; 6 - mixed vascularization of the cornea
Chemosis of the conjunctiva - pinching of the conjunctiva within the palpebral fissure due to severe swelling.
Eyeball position
When analyzing the position of the eye in the orbit, attention is paid to the protrusion, retraction or displacement of the eyeball. In some cases, the position of the eyeball is determined using a Hertel mirror exophthalmometer. The following options for the position of the eyeball in the orbit are distinguished: normal, exophthalmos (anterior protrusion of the eyeball), enophthalmos (retraction of the eyeball), lateral displacement of the eye and anophthalmos (absence of the eyeball in the orbit).
Exophthalmos(proportion of the eye anteriorly) is observed in thyrotoxicosis, trauma, orbital tumors. For differential diagnosis In these conditions, reposition of the protruding eye is performed. For this purpose, the doctor presses the patient’s eyeballs through the eyelids with his thumbs and assesses the degree of their displacement inside the orbit. With exophthalmos caused by a neoplasm, difficulty in repositioning the eyeball into the orbital cavity is determined.
Enophthalmos(retraction of the eyeball) occurs after fractures of the orbital bones, with damage to the cervical sympathetic nerve (as part of Bernard-Horner syndrome), as well as with atrophy of retrobulbar tissue.
Lateral displacement of the eyeball can be due to a space-occupying formation in the orbit, an imbalance in the tone of the extraocular muscles, a violation of the integrity of the orbital walls, or inflammation of the lacrimal gland.
Motility disorders of the eyeball are more often the result of diseases of the central nervous system and paranasal sinuses
nose When examining the range of motion of the eyeballs, the patient is asked to follow the movement of the doctor’s finger to the right, left, up and down. They observe how far the eyeball reaches during the study, as well as the symmetry of eye movements. The movement of the eyeball is always limited towards the affected muscle.
Lacrimal organs
The lacrimal gland is normally inaccessible to our examination. It protrudes from under the upper edge of the orbit when pathological processes(Mikulich syndrome, tumors of the lacrimal gland). The accessory lacrimal glands located in the conjunctiva are also not visible.
When examining the lacrimal openings, pay attention to their size, position, and their contact with the conjunctiva of the eyeball when blinking. When you press on the area of the lacrimal sac, there should be no discharge from the lacrimal openings. The appearance of tears indicates a violation of the outflow of tear fluid through the nasolacrimal duct, and mucus or pus indicates inflammation of the lacrimal sac.
Tear production is assessed using the Schirmer test: a strip of filter paper 35 mm long and 5 mm wide with one pre-curved end is inserted behind the lower eyelid of the subject (Fig. 4.3). The test is carried out with eyes closed. After 5 minutes, the strip is removed. Normally, a section of the strip more than 15 mm long is wetted with tears.
Rice. 4.3. Schirmer test
Functional patency lacrimal ducts evaluate several methods.
Tubular test. Instilled into the conjunctival sac
3% collargol solution? or 1% sodium fluorescein solution.
Normally, due to the suction function of the eye tubules,
The apple becomes discolored within 1-2 minutes (positive tubular test).
Nasal test. Before instilling dyes into the conjunctival sac under the lower turbinate a probe with a cotton swab is inserted. Normally, after 3-5 minutes, the cotton swab is stained with dye (positive nasal test).
Washing the lacrimal ducts. The lacrimal punctum is expanded with a conical probe and the patient is asked to tilt his head forward. A cannula is inserted into the lacrimal canaliculus 5-6 mm and a sterile 0.9% sodium chloride solution is slowly poured in using a syringe. Normally, fluid flows out of the nose in a trickle.
Side (focal) lighting method
This method is used to study the conjunctiva of the eyelids and eyeball, sclera, cornea, anterior chamber, iris and pupil (Fig. 4.4).
The study is carried out in a darkened room. The table lamp is installed at eye level of the seated patient, at a distance of 40-50 cm, to the left and slightly in front of him. IN right hand the doctor takes a +20 diopter magnifying glass and holds it at a distance of 5-6 cm from the patient’s eye, perpendicular to the rays coming from the light source, and focuses the light on the area of the eye that is to be examined. Thanks to the contrast between a brightly lit small area of the eye and the unlit neighboring parts of it, changes are better visible. When examining the left eye, the doctor fixes his right hand, resting his little finger on zygomatic bone, when examining the right eye - on the back of the nose or forehead.
The sclera is clearly visible through the transparent conjunctiva and is normally white. A yellow coloration of the sclera is observed in jaundice. Staphylomas may be observed - dark brown areas of protrusion of sharply thinned sclera.
Cornea. Ingrown blood vessels into the cornea occurs when pathological conditions. Minor defects
Rice. 4.4.Side (focal) lighting method
The corneal epithelium is detected by staining with 1% sodium fluorescein solution. The cornea may have opacities of varying location, size, shape and intensity. The sensitivity of the cornea is determined by touching the center of the cornea with a cotton wick. Normally, the patient notices the touch and tries to close the eye (corneal reflex). When sensitivity decreases, the reflex is caused only by placing a thicker part of the wick. If the corneal reflex could not be evoked in the patient, then there is no sensitivity.
Anterior chamber of the eye. The depth of the anterior chamber is assessed when viewed from the side by the distance between the light reflexes appearing on the cornea and iris (normally 3-3.5 mm). Normally, the moisture in the anterior chamber is completely transparent. In pathological processes, an admixture of blood (hyphema) or exudate may be observed in it.
Iris. Eye color is usually the same on both sides. A change in the color of the iris of one eye is called anisochromia. It is more often congenital, less often - acquired (for example, with inflammation of the iris). Sometimes iris defects are found - colobomas, which can be peripheral or complete. Severing the iris from the root is called iridodialysis. With aphakia and lens subluxation, iris trembling (iridodonesis) is observed.
The pupil is visible as a black circle in side lighting. Normally, the pupils are the same in size (2.5-4 mm in moderate lighting). Constriction of the pupil is called miosis, extension - mydriasis, different pupil sizes - anisocoria.
The reaction of the pupils to light is tested in a dark room. The pupil is illuminated with a flashlight. When one eye is illuminated, its pupil constricts (direct pupil reaction to light), as well as the pupil of the other eye constricts (cooperative pupil reaction to light). The pupillary reaction is considered “alive” if, under the influence of light, the pupil quickly narrows, and “sluggish” if the pupil reaction is slow and insufficient. The pupil may not react to light.
The reaction of the pupils to accommodation and convergence is checked when moving the gaze from a distant object to a close object. Normally, the pupils constrict.
The lens is not visible in lateral lighting, except in cases of clouding (total or anterior).
Transmitted light examination
This method is used to assess the transparency of the optical media of the eye - the cornea, anterior chamber moisture, lens and vitreous body. Since the transparency of the cornea and the moisture of the anterior chamber can be assessed with lateral illumination of the eye, a study with transmitted light is aimed at analyzing the transparency of the lens and vitreous body.
The study is carried out in a darkened room. The lighting lamp is placed to the left and behind the patient. The doctor holds an ophthalmoscopic mirror in front of his right eye and, directing a beam of light into the pupil of the eye being examined, examines the pupil through the opening of the ophthalmoscope.
The rays reflected from the fundus (mainly from the choroid) are pink. With transparent refractive media of the eye, the doctor sees a uniform pink glow of the pupil (pink reflex from the fundus). Various obstacles in the path of the light beam (that is, clouding of the eye media) delay some of the rays, and against the background of a pink glow appear dark spots of different shapes and sizes. If, when examining the eye in lateral illumination, opacities in the cornea and anterior chamber aqueous are not detected, then the opacities visible in transmitted light are localized either in the lens or in the vitreous body.
Ophthalmoscopy
The method allows you to assess the condition of the fundus (retina, optic nerve head and choroid). Depending on the method of implementation, ophthalmoscopy is distinguished in reverse and direct form. This study is easier and more effective to carry out with a wide pupil.
Reverse ophthalmoscopy
The study is carried out in a darkened room using a mirror ophthalmoscope (a concave mirror with a hole in the center). The light source is placed to the left and behind the patient. With ophthalmoscopy, a uniform glow of the pupil is first obtained, as in a transmitted light study, and then a +13.0 diopter lens is placed in front of the eye being examined. The lens is held with the thumb and index finger of the left hand, resting on the patient's forehead with the middle finger or little finger. Then the lens is moved away from the eye being examined by 7-8 cm, gradually achieving image magnification
pupil so that it occupies the entire surface of the lens. The image of the fundus during reverse ophthalmoscopy is real, enlarged and inverted: the top is visible from below, the right part is visible from the left (that is, the opposite, which explains the name of the method) (Fig. 4.5).
Rice. 4.5.Indirect ophthalmoscopy: a) using a mirror ophthalmoscope; b) using an electric ophthalmoscope
An examination of the fundus is carried out in a certain sequence: they start with the optic nerve head, then examine the macular region, and then the peripheral parts of the retina. When examining the optic disc of the right eye, the patient should look slightly past the doctor’s right ear; when examining the left eye, at the doctor’s left earlobe. The macular area is visible when the patient looks directly into the ophthalmoscope.
The optic disc is round or slightly oval in shape with clear boundaries, yellowish-pink in color. In the center of the disc there is a depression (physiological excavation), caused by bending of the optic nerve fibers.
Fundus vessels. The central retinal artery enters and exits through the center of the optic disc central vein retina. Once the main trunk of the central retinal artery reaches the surface of the disc, it divides into two branches - superior and inferior, each of which branches into the temporal and nasal. The veins follow the course of the arteries; the ratio of the caliber of arteries and veins in the corresponding trunks is 2:3.
The macula looks like a horizontal oval, slightly darker than the rest of the retina. In young people, this area is bordered by a strip of light - the macular reflex. The central fovea of the macula, which has an even darker color, corresponds to the foveal reflex.
Direct ophthalmoscopy used for detailed examination of the fundus using a hand-held electric ophthalmoscope. Direct ophthalmoscopy allows you to examine small changes in limited areas of the fundus at high magnification (14-16 times, while with reverse ophthalmoscopy the magnification is only 4-5 times).
Ophthalmochromoscopy allows you to examine the fundus of the eye using a special electroophthalmoscope in purple, blue, yellow, green and orange light. This technique allows you to see early changes in the fundus.
A qualitatively new stage in the analysis of the condition of the fundus is the use of laser radiation and computer image assessment.
Measuring intraocular pressure
Intraocular pressure can be determined using indicative (palpation) and instrumental (tonometric) methods.
Palpation method
During the examination, the patient's gaze should be directed downward, eyes closed. The doctor fixes the III, IV and V fingers of both hands on the patient’s forehead and temple, and places the index fingers on the upper eyelid of the eye being examined. Then, alternately with each index finger, the doctor performs light pressing movements on the eyeball several times. The higher the intraocular pressure, the denser the eyeball and the less its walls move under the fingers. Normally, the wall of the eye collapses even with light pressure, that is, the pressure is normal (short notation T N). Eye turgor may be increased or decreased.
There are 3 degrees of increase in eye turgor:
The eyeball is crushed under the fingers, but for this the doctor applies more force - intraocular pressure is increased (T+ 1);
The eyeball is moderately dense (T+ 2);
Finger resistance has been dramatically increased. The doctor's tactile sensations are similar to those felt when palpating the frontal area. The eyeball almost does not fall under the finger - intraocular pressure is sharply increased (T+ 3).
There are 3 degrees of reduction in eye turgor:
The eyeball feels softer to the touch than normal - intraocular pressure is reduced (T -1);
The eyeball is soft, but retains its spherical shape (T -2);
During palpation, no resistance to the wall of the eyeball is felt at all (as when pressing on the cheek) - intraocular pressure is sharply reduced. The eye does not have a spherical shape, or its shape is not preserved upon palpation (T -3).
Tonometry
There are contact (applanation using a Maklakov or Goldman tonometer and impression using a Schiotz tonometer) and non-contact tonometry.
In our country, the most common tonometer is Maklakov, which is a hollow metal cylinder 4 cm high and weighing 10 g. The cylinder is held with a grip handle. Both bases of the cylinder are expanded and form platforms onto which a thin layer of special paint is applied. During the examination, the patient lies on his back, his gaze is fixed strictly vertically. A solution is instilled into the conjunctival cavity local anesthetic. The doctor widens the palpebral fissure with one hand, and with the other sets the tonometer vertically on the eye. Under the weight of the load, the cornea flattens, and at the point of contact of the platform with the cornea, the paint is washed away with a tear. As a result, a circle devoid of paint is formed on the tonometer platform. An imprint of the area is made on paper (Fig. 4.6) and the diameter of the unpainted disc is measured using a special ruler, the divisions of which correspond to the level of intraocular pressure.
Normally, the level of tonometric pressure ranges from 16 to 26 mmHg. It is higher than the true intraocular pressure (9-21 mm Hg) due to the additional resistance provided by the sclera.
Topographyallows you to assess the rate of production and outflow of intraocular fluid. Intraocular pressure is measured
Rice. 4.6.Flattening of the cornea with the Maklakov tonometer platform
for 4 minutes while the sensor is on the cornea. In this case, a gradual decrease in pressure occurs, as part of the intraocular fluid is forced out of the eye. Based on tonography data, one can judge the cause of changes in the level of intraocular pressure.
INSTRUMENTAL METHODS OF EXAMINATION
Biomicroscopy
Biomicroscopy- This is intravital microscopy of eye tissue using a slit lamp. The slit lamp consists of an illuminator and a binocular stereomicroscope.
Light passing through the slit diaphragm forms a light slice of the optical structures of the eye, which is viewed through a slit lamp stereomicroscope. By moving the light slit, the doctor examines all structures of the eye with a magnification of up to 40-60 times. Additional observational, photo- and tele-recording systems, and laser emitters can be introduced into the stereomicroscope.
Gonioscopy
Gopioscopy- a method of studying the angle of the anterior chamber, hidden behind the limbus, using a slit lamp and a special device - a gonioscope, which is a system of mirrors (Fig. 4.7). Van Beuningen, Goldmann and Krasnov gonioscopes are used.
Gonioscopy allows you to detect various pathological changes in the angle of the anterior chamber (tumors, foreign bodies, etc.). Especially
it is important to determine the degree of openness of the angle of the anterior chamber, according to which a wide, medium width, narrow and closed corner.
Rice. 4.7. Gonioscope
Diaphanoscopy and transillumination
Instrumental examination of intraocular structures is carried out by directing light into the eye through the sclera (with diaphanoscopy) or through the cornea (with transillumination) using diaphanoscopes. The method makes it possible to detect massive hemorrhages in the vitreous body (hemophthalmos), some intraocular tumors and foreign bodies.
Echoophthalmoscopy
Ultrasound research method structures of the eyeball are used in ophthalmology to diagnose retinal and choroidal detachment, tumors and foreign bodies. It is very important that echoophthalmography can also be used in cases of opacification of the optical media of the eye, when the use of ophthalmoscopy and biomicroscopy is impossible.
Doppler ultrasound allows you to determine linear speed and the direction of blood flow in the internal carotid and orbital arteries. The method is used for diagnostic purposes for eye injuries and diseases caused by stenotic or occlusive processes in these arteries.
Entoptometry
Picture of functional state retinas can be obtained by using entoptic tests(Greek ento- inside, orto- I see). The method is based on the patient’s visual sensations, which arise as a result of the influence of adequate (light) and inadequate (mechanical and electrical) stimuli on the retinal receptive field.
Mechanophosphene- the phenomenon of feeling a glow in the eye when pressing on the eyeball.
Autoophthalmoscopy- a method that allows you to assess the safety of the functional state of the retina in opaque optical environments of the eye. The retina functions if, with rhythmic movements of the diaphanoscope along the surface of the sclera, the patient notices the appearance of visual patterns.
Fluorescein angiography of the retina
This method is based on serial photography of the passage of sodium fluorescein solution through the retinal vessels (Fig. 4.8). Fluorescein angiography can be performed only in the presence of transparent optical media of the ocular
Rice. 4.8.Retinal angiography (arterial phase)
apple In order to contrast the retinal vessels, a sterile 5-10% sodium fluorescein solution is injected into the cubital vein.
VISUAL EXAMINATION IN CHILDREN
When conducting an ophthalmological examination of children, it is necessary to take into account their fatigue and the inability to hold gaze for long periods of time.
An external examination in young children (up to 3 years old) is carried out with the help of a nurse who fixes the child’s arms, legs and head.
Visual functions in children under one year of age can be assessed indirectly by the appearance of tracking (end of the 1st and beginning of the 2nd month of life), fixation (2 months of life), danger reflex - the child closes his eyes when an object quickly approaches the eye (2-3 months life), convergence (2-4 months of life). Starting from the age of one year, children's visual acuity is assessed by showing them toys of different sizes from different distances. Children aged three years and older are examined using children's optotype tables.
The boundaries of the visual field in children aged 3-4 years are assessed using an approximate method. Perimetry is used from the age of five. It should be remembered that in children the internal boundaries of the visual field are somewhat wider than in adults.
Intraocular pressure in young children is measured under anesthesia.
