Federal State Budgetary Educational Institution of Higher Education «I.P.Pavlov Ryazan State Medical University» of the Ministry of Healthcare of the Russian Federation; Department of eye and ENT diseases A.V. Kolesnikov, L.V. Mironenko, M.A. Kolesnikova, V. A. Sokolov PRINCIPLLES OF EXAMINATION OF PATIENTS WITH DIFFERENT OPHTHALMIC PATHOLOGIES Methodical recommendations for foreign students of the medical faculties (in English medium) Ryazan 2018 Федеральное государственное бюджетное образовательное учреждение высшего образования «Рязанский государственный медицинский университет имени академика И.П. Павлова» Министерства здравоохранения Российской Федерации (ФГБОУ ВО РязГМУ Минздрава России) Кафедра глазных и ЛОР болезней А.В. Колесников, В.А. Соколов, М.А. Колесникова, Л.В. Мироненко ОСОБЕННОСТИ ОБСЛЕДОВАНИЯ ПАЦИЕНТОВ С РАЗЛИЧНОЙ ОФТАЛЬМОЛОГИЧЕСКОЙ ПАТОЛОГИЕЙ Методические рекомендации для самостоятельной работы иностранных студентов лечебного факультета (на английском языке) Рязань 2018 г. 2 UDС 617.7-07 (075.83) BBС 56.7 P 92 Reviewers: L.A. Zhukova, Ph.D., assistant professor of therapeutical department with family medicine caurse of the P.Gs. education faculty V.A. Zhadnov, M.D., assistant professor of the department of nervous system diseases and neurosurgery Authors: A.V. Kolesnikov, Ph.D., assistant professor M.A. Kolesnikova, Ph.D., assistant professor L.V. Mironenko, Ph.D., assistant professor V. A. Sokolov, M.D., professor Translated by Kardicheva L.I. P 92 Principlles of examination of patients with different ophthalmic pathologies: methodical recommendation for foreign students of the medical faculties (in English medium) / A.V. Kolesnkov [and others]; FSBEI HE RyazSMU MOH, – Ryazan: TSD and OP, 2018. – 76p. The student independent work is the development of the creative abilities. It plays a key role in the system of the education process. Students can see the ophthalmologic patients first at ophthalmology department. The examination of patients has many new specific characteristics. As a rule, students working independently, have difficulties to gain the anamnesis and choose necessary methods of examination to determine the symptoms of a disease. The aim of the manual is to arm students with skills of successful work. UDС 617.7-07 (075.83) BBС 56.7 © Authors, 2018 © FSBEI HE RyazSMU MOH, 2018 3 УДК 617.7-07 (075.83) ББК 56.7 O-754 Рецензенты: Л.А. Жукова, доцент кафедры терапии и семейной медицины ФДПО с курсом медико-социальной экспертизы ФГБОУ ВО РязГМУ Минздрава России В.А.Жаднов, доктор мед. наук, доцент кафедры нервных болезней и нейрохирургии Авторы: А.В. Колесников, к.м.н., доц., зав. кафедрой глазных и ЛОР-болезней; М.А. Колесникова, к.м.н., доц. кафедры глазных и ЛОР-болезней; В.А. Соколов, д.м.н., профессор кафедры глазных и ЛОР-болезней; Л.В. Мироненко, к.м.н., доц. кафедры глазных и ЛОР-болезней O-754 Особенности обследования пациентов с различной офтальмологической патологией: методические рекомендации для самостоятельной работы иностранных студентов лечебного факультета (на английском языке) / А.В. Колесников [и др.]; ФГБОУ ВО РязГМУ Минздрава России. – Рязань: ОТС и ОП, 2018. – 76 с. В настоящих рекомендациях излагаются все наиболее распространенные методы обследования органа зрения. Приводится краткое описание современных приборов, с помощью которых производится офтальмологическое обследование. Данные методические рекомендации предназначены для самостоятельной работы иностранных студентов лечебного факультета и помогут им в подготовке к практическим занятиям по офтальмологии. УДК 617.7-083.98 (075.83) ББК 56.7 © ФГБОУ ВО РязГМУ Минздрава России, 2018 © Авторы, 2018 4 Contents Preface………………………………………………………………….…..6 Examination of a patient with anomalies of refraction…………………....6 Examination of a patient with the eyelid diseases……………………... 11 Examination of a patient with lachrymals diseases……………………..…16 Examination of a patient with strabismus…………………………….…...20 Examination of a patient with diseases of the conjunctiva………………..24 Examination of a patient with keratitis……………………………………32 Examination of a patient with iridocyclitis………………………….…….38 Examination of a patient with pathology of the crystalline lens…………..45 Examination of a patient with glaucoma…………………………….……54 Examination of a patient with ocular injuries………………………….….58 Conclusion…………………………………………………………………75 Literature…………………………………………………………………..76 5 PREFACE Students deal with eye pathology on the ophthalmology department. That is why students must learn characteristics of ophthalmic examination. Various eye pathology must be evaluated by special methods of examination. Given methodical recommendations will help foreign students to acquire skills of independent work with patients having various ophthalmologic pathology. I. EXAMINATION OF A PATIENT WITH ANOMALIES OF REFRACTION Anamnesis: Characteristic complaints. The start of the failing sight arise. Possible reasons of failing sight (as a result of previous diseases). Previous treatment (correction, medicamental therapy) Physical examination: 1. Examination of central visual acuity without correction. 2. Examination of clinical refraction by the subjective method (adjusting of correcting eyeglasses). In the case of nearsightedness, we must take first eyeglass, with which the patient has total acuity of vision; in the case of longsightedness we must take last eyeglass, in order not to switch the accomodation in the case of nearsightedness and to relax completely the accomodation in the case of longsightedness. 3. Examination of clinical refraction by objective methods (skiascopy, refractometry, ophthalmometry), in the case of cycloplegia. 4. Examination of presbyopia and its correction. 5. External examination of eyes. 6. Examination of refractive medium by the method of lateral light: examination of the cornea, the anterior chamber, the lens. 6 7. Examination of deep refractive medium by passing light: examination of the lens, and vitreous body. 8. Ophthalmoscopy. 9. Writing out a prescription for eyeglasses. Practical skills: 1. To write down the results of visual acuity examination with correction of refraction anomalies. 2. To use an optic lenses kit. 3. To differentiate concave lenses from convex lenses and to determine their optic power lenses by the neutralization method. 4. To determine clinical refraction by subjective method. Adjusting glasses in myopia, hypermetropia and presbyopia. 5. To determine the pupillate distance. 6. To determine the optic centers in glasses. 7. To write out a prescription for eyeglasses and bifocals. 8. To prepare the working place for skiascopy and to arrange the approximate examination (to see the shadow shift in dilated pupil). 9. To determine the near visual point. 10.To calculate the accommodation range. Situation tasks: Refraction. 1. A 30-year-old patient has the following refraction: OD=E OS=M 4.0 D Prescribe correcting glasses. 2. A 20-year-old patient has the following refraction: OD=M 2.0 D OS=M 5.0 D. Prescribe correcting glasses. 3. A 10-year-old patient has refraction OD=M 2.0 D OS=H 5.0 D. Prescribe correcting glasses. 7 4. A 50-year-old patient has refraction OD=H 5.0 D OS= M 2.0 D. Prescribe correcting glasses. 5. A 15-year-old child has refraction OD=H 5.0 D OS=M 2.0 D. Prescribe correcting glasses. 6. A 40 year-old patient’s refraction is OD=H 2.0 D OS =M 1.0 D. Prescribe glasses for a short distance work. 7. Prescribe bifocals for a 70-year-old hypermetropic patient with 3.0 D. 8. Prescribe correcting glasses for a 75-year-old patient with emmetropic refraction. 9. Where is the far visual point located in a myopic patient whose volume of accommodation is 12.0 D? 10. The far visual point is located at a distance of 50 cm in front of the eye. Define the kind of clinical refraction and prescribe correcting glasses. 11. A patient admitted to infection department on account of food poisoning with sausage noticed visual impairment: decrease in near vision whereas distance vision remained normal. On checking visual acuity on the chart she could read from 5 to 10 lines with both eyes. How can visual impairment be explained? 12. After preventing examination a 7-year-old boy was directed to an oculist on account of decrease in vision. The boy had noticed 8 decrease in distance vision about a year before. His near vision was normal. Examination showed: Vis OD=0.2-2.0 D=1.0 OS=0.3-1.75 D=1.0 Make a diagnosis and give recommendations. 13.A 40 year-old teacher has been using glasses +1.5 D on reading and writing for five years, prescribed to him by an oculist to whom he came with complaints of fast fatigability of the eyes and headaches on reading. Wearing these glasses he began to see long distances better, though he had thought that his distance vision was excellent. But lately he can’t see small print well. How can you explain visual impairment in the patient? What examinations and prescriptions will be required? 14. Is accommodation volume equal in two students of the same age having respectively myopia with 0.3 D and hypermetropia with 2.0 D? Calculate this volume if it is known that the near visual point lies at 11.5 cm in the hypermetropic student and at 7.2 cm in the myopic student. 15. A 15-year-old patient complains of decreased visual acuity in both eyes since childhood, rapid fatigability, pain in the eyes and headache on intensive work. She repeatedly consulted a doctor who prescribed glasses for her. But the glasses didn’t cause significant improvement. Examination showed: Vis OD=0.06-6.0D=0.9 OS=0.1 correction not accepted During skiascopic investigation it was revealed: myopia of 6.0D in the right eye and hypermetropia of 0.3D in the left eye. Explain the character of visual impairment and means of treatment. 16. At the end of the school year a pupil began to complain of decrease in distance vision, rapid fatigability of the eyes on reading, headache. At the beginning of the school year visual acuity in both eyes 9 equaled 1.0. During examination it was revealed: visual acuity in both eyes was 0.1; correction –2,5D increased it to 1.0. What disease can be supposed? What would you undertake to make a more exact diagnosis? 17. A 30-year-old patient has broken glasses without which she can’t see well. She has been suffering from myopia since childhood and worn glasses since the 1st class. The patient repeatedly changed her glasses for stronger ones as myopia has been progressing. During last 5-6 years doctors can’t select glasses with which she could see long distance as well as before. Vis OD=0.02-18.0 D=0.2 OS= 0.01-15.0 D=0.3 The eye fundus: large staphylomae around the disks of optic nerves, spots of pigmentation in the mascular zones, numerous big white focuses of chorioretinal distrophy in the paramacular zone. Make a diagnosis, prescribe correction and treatment. 18. A 50-year-old engineer has come to an oculist for consultation. He has been using glasses for a short distance since he was 35. Last time an oculist prescribed glasses with +1.5 D five years ago. Now wearing these glasses the patient can see short distances worse. He feels pressure in the eyes and headaches after work. He also complains of decrease in distant vision though earlier he could see long distances well. No pathological changes in the eyes have been revealed. Vis OD=0.4-2.0 D=1.0 OS=0.3-2.0 D=1.0 Formulate a diagnosis and prescribe treatment. 10 II. EXAMINATION OF A PATIENT WITH THE EYELID DISEASES The most typical complaints are sharply full-grown reddening of eyelid with painful swell; frequent sties, frequent or permanent reddening of the eyelid margins, itch, frequent winking, foamy accumulation in the external canthus, shedding of eyelashes; painless pea-like infiltration (hailstone); incremental birthmarks, warts, ulcerations; entropion, ectropion, twitching and closing of eyes tight, unclosing eye-slit (sleep with an open eye), lowering upper eyelid; overhand pleats of skin, oedema of eyelids in the morning, one-sided oedema of eyelids (livid spot, bruise), cosmetic defects. Anamnesis: 1. The beginning of the disease. 2. What are the reasons of the diseases to the patient’s mind? 3. The presence of systemic diseases. 4. Previous diseases of eyes. 5. Profession of the patient, the presence of professional insalubrities. Physical examination: 1. Examination of central visual acuity without correction and with correction. 2. External examination of eyes with the help of binocular magnifier. Pay attention to the appearance, size and form of eye-slit and eyelids (eye-slit is pared-down, dilated, short-cut, anomalous; eyelid is enlarged, incrassate, skin’s pleats are smoothed, there are deformations, defects, scarring) should be drawn. The skin colour (pale, scarlet, cyanotic, icteric, violet), its surface (smooth, shining, uneven with birthmark, wart, ulceration, obtrusive new growth, eminent callous prominence, mobility subject to tissues) should be determined. If there is a local swell, it should be determined, manually (hard, solid, resilient, elastic, pasty, fluctuating, pulsatile, 11 crepitant, ect.). If there is an oedema, it should be determined, what it is: “cold” (pale, watery, soft) or “hot” (red, strained, painful infiltration). The ciliary margin of the lids (incrassate, hyperemic, smooth, even, uneven, ulcerous), density of the eyelashes, growth regularity, wisp agglutination, presence of alopecia, scales, ulcerations, scabs by root of eyelashes should be determined. The position of eyelid to the surface of eyeball should be determined (normal, solid adjacency, inadhesive, entropion, ectropion). The tone of orbicularis muscle can be determined by ability of lower eyelid to come back to the initial position after drawing it off. Practical skills: 1. To evert the lid. 2. To prepare a solid tampon turned over the end of a probe or a glass rod for greasing of the lid margins. 3. To grease and cauterize the lid margins in blepharitises and sties. 4. To do the epilation of eyelaches. 5. To place some ointment behind the eyelids. 6. To learn UHF-therapy, therapy of dry warm in eyelids diseases (blues light, paraffin, dry compress). 7. To massage of the eyelids by a glass rod. 8. To put a plaster to avoid spastic entropion of the eyelids. Термины по теме – The terms on the theme ВЕКО(И) EVELID(S) upper lid lower ltd abscess of the eyelid adenocarcinoma of the lid inflammation of the lid margins, blepharitis lid retraction lid evertion, ectropion верхнее веко нижнее веко абсцесс века аденокарцинома века воспаление краев век, блефарит втяжение века выворот века, эктропион 12 гемангиома века дефект края века, колобома века заворот века контагиозный моллюск век ксантелазма век, опущение/птоз [верхнего] века, отек века (век) отрыв века разрыв века рак кожи века базальноклеточный рак кожи века ранение века ресничный край век сальные железы век, мейбомиевы железы свисание истонченной кожи верхнего века, блефарохалазис сращение век между собой и глазным яблоком, анкилоблефарон lid hemangioma lid coloboma, coloboma palpebrale blepharelosis, entropion molluscum contagiosum of the eyelids xanthelasma palpebrarum[upper] lid ptosis edematous lid(s) lid abruption lid rupture skin carcinoma of the lid skin basal cell carcinoma of the lid lid injury ciliary margin of the lids meibomian glands blepharochalasis ankyloblepharon флегмона века lid phlegmon фурункул века lid furuncle экзема кожи века lid skin eczema глазная щель, щель век eye-slit, ocular fissure кожный рог спазм вековой части круговой мышцы глаза, блефароспазм халазнон, градина эпикантус ресницы ячмень внутренний ячмень наружный ячмень cutaneous horn blepharospasm chalazion epicanthus eyelashes sty, hordeolum inner/ internal sty outer/external sty 13 вывернуть веко вывернуть веко с помощью векоподъемника (стеклянной палочки) слипаться (о веках) смыкать веки, закрывать глаз(а) to evert a lid to evert a lid with the aid of an eyelid lifter (glass rod) to stick together (of lids) to close lids, to close eye(s) БЛЕФАРИТ ангулярный блефарит мейбомиевый блефарит простой/чешуйчатый блефарит, себорея век язвенный блефарит розацеа-блефарит БЛЕФАРОСПАЗМ истерический блефароспазм клоннческий блефароспазм рефлекторный блефароспазм симптоматический блефароспазм старческий блефароспазм тонический блефароспазм эссенцнальный блефароспазм BLEPHARITIS angular blepharitis meibomian blepharitis simple/squamous blepharitis ulcerative blepharitis rosacea blepharitis BLEPHAROSPASM hysterical blepharospasm clonic blepharospasm reflex blepharospasm symptomatic blepharospasm senile blepharospasm tonic blepharospasm essential blepharospasm TURNING OUT OF AN EYELID. EVERS1ON OF AN EYELID. ECTROPION, ECTROPIUM atonic eversion of an eyelid paralytic eversion of an eyelid, paralytic ectropion cicatricial eversion of an eyelid spastic eversion of an eyelid ВЫВОРОТ ВЕКА, ЭКТРОПИОН атонический выворот века паралитический выворот века рубцовый выворот века спастический выворот века старческий выворот века senile ectropion ГЛАЗНАЯ ЩЕЛЬ, ЩЕЛЬ ВЕК EYE-SLIT, OCULAR FISSURE узкая глазная щель narrow eye-slit широкая глазная щель wide eye-slit 14 смыкание глазной щели неполное смыкание глазной щели, лагофтальм сужение глазной щели угол глазной щели укорочение и сужение глазной щели, блефарофимоз ширина глазной щели ОТЕК ВЕКА (ВЕК) аллергический отек век ангионевротический отек век травматический отек век ПТОЗ ВЕКА (ВЕК), БЛЕФАРОПТОЗ врожденный птоз века двусторонний птоз век миогенный птоз века односторонний птоз века паралитический птоз век полный (неполный) птоз века приобретенный птоз века старческий птоз век поза звездочета РЕСНИЦА (Ы) густые (редкие) ресницы неправильный рост ресниц, трихиаз века полное выпадение ресниц, мадароз прекращение роста ресниц closing of eye-slit incomplete closing of eye-slit, lagophthalmos narrowing of the eye-slit canthus blepharophimosis eye-slit width LID EDEMA allergic lid edema angioneurotic lid edema traumatic lid edema EYELID PTOSIS, BLEPHAROPTOSIS congenital eyelid ptosis bilateral eyelid ptosis myogenic/myogenetic/myogenous ptosis unilateral eyelid ptosis paralytic eyelid ptosis complete (incomplete) eyelid ptosis acquired eyelid ptosis senile eyelid ptosis posture of an astrologer EYELASH(ES) dense (thin) eyelashes trichiasis of the lid total falling out of eyelashes non-growth of eyelashes 15 III. EXAMINATION OF A PATIENT WITH LACHRYMALS DISEASES The most typical complaints are persistent eyewatering especially caused by wind. Besides of it, some patients complain of discharge of pus, protrusion in projection of lacrimal sac and recurrent abscesses. In the case of dacryocystitis in infants, parents are notice eyewatering and pus discharge from one eye or both ones during first days or weeks of living. Anamnesis: 1. The beginning of the disease. 2. The reasons of the disease. 3. Previous diseases of eyes. 4. Profession of the patient, the presence of professional insalubrities. Physical examination: the most frequent reasons of eyewatering are: 1.Unsubmerged lacrimal points into the lacrimal lake touching softly the eyelid margins (ectropion). 2. Inflammation of the ducts, lacrimal sac, nasolacrimal duct. 3. Narrowing or obstruction at any part of the lacrimal ducts. The physical examination begins with external examination. Pay attention to eyelids position, size and location of lacrimal point. They must adjoin the eyeball and submerge into the lacrimal lake in the region of semilunar pleat. The aperture of lacrimal opening is about 0.5 mm in average. Plentiful accumulation of tear along the back margin of lower eyelid (dilation “rivrus lacrimalis”) is a definite sign of disturbance of lacrimal abstraction. The region of lacrimal sac should be carefully examined. A protrusion under medial palpebral commissure which is sometimes so large that it take a form of big kidney bean appearing through the fairy skin (dropsy of lacrimal sac) may be observed. 16 The cardinal sign of dacryocystitis is the pus discharge from lacrimal points by thumb pressure at region of lacrimal sac. The pressure should be done under medial palpebral ligament bottom-up. The examination of functional permeability of lacrimal ducts should be performed in every case. To do it the tear should be dyed (put with an dropper the 3 % solution of collargol or 1 % solution of fluorescein in eye) and determine a ductus and nasal colour tests. If nasal test is negative or slowed, wash out of lacrimal ducts with physiological solution from syringe with dull thick needle or special cannula. Diagnostic probing of the lacrimal ducts is not recommended because of possible injure of mucous tunic with subsequent formation of scarry strictures. Sometimes, a rontgenogram with infill their contrast substance (30 % solution of iodolipol) should be performed to get the more clear picture of the lacrimal ducts outlines. Practical skills: 1. To examine the lacrimal ducts permeability by the ductus and nasal tests. 2. To prepare the tool kit for washing out lacrimal ducts. 3. To wash out the lacrimal ducts. 4. To dilate the lacrimal point by a conical probe. 5. To squeeze out pus from lacrimal sac in the case of chronic dacryocystitis. 6. To observe probing lacrimal ducts in the case of dacryocystitis in infants. Situation tasks: Diseases of lacrimal organs. 1. A 55-year-old patient has had an incremental film in the left eye for several years. Lately he can see worse with this eye. Examination shows: Vis OD=1.0 / VisOS=0.4, correction not accepted 17 The right eye is normal. The left eye: from the internal corner a pink film is crawling over the cornea. The film has a form of a triangle which apex reaches the central corneal section and the wide base is facing the semilunar fold. Make a diagnosis and administer treatment. 2. A 48-year-old patient complains of redness and edema of the eyelids with sharp painfulness at the internal corner of the right eyelid. Pain and slight swelling at this place appeared three days ago. Last night she couldn’t sleep because of severe pain, fever and temperature to 38.5˚. Watering and purulent discharge have troubled her for several months. On examination: Vis OD=1.0. There is an evident edema and hyperemia of the eyelids, spreading over the cheek. There is a dense crimson infiltrate with sharp painfulness on palpation at the internal corner of the eye. Fluctuation is present in the central section. Formulate a diagnosis and means of treatment. 3. A 74-year-old patient complains of blindness, watering and purulent discharge from the left eye. The symptoms have troubled her for three days. Examination shows: Vis OD=0.3+2.0 D=1.0 Vis OS=1/ ∞ pr 1.c. OD: the supplementary apparatus is unaltered, optic mediums are transparent, the eye fundus is normal. OS: there is excessive watering at the margins of the lower eyelid. When depressing with a finger under the medial ligament of the eyelids the tear points extract profuse purulent discharge. The conjunctiva is hyperemic. The cornea is transparent, the anterior chamber is of medium depth. The pattern of the iris is distinct; it has the same color as the right one. The pupil is grey with normal reactions. A reflex from the eye fundus is absent. Make a diagnosis and a plan of treatment. 18 4. Watering and purulent discharge appeared in a child of 3 weeks old. When depressing on the region of the lacrimal sac the tear points extract mucous-purulent discharge. Form a diagnosis and administer treatment. 5. A 34-year-old patient has: OD: passive congestion in the veins of the forehead, ptosis, immobility of the eyeball: slight exophthalmos, impairment of sensitivity of the anterior section of the eye, midriasis and accommodation paralysis. OS is normal. Make a diagnosis. Термины по теме – The terms on the theme СЛЕЗНЫЕ ОРГАНЫ LACRIMAL ORGANS носослезный канал/проток nasolacrimal canal/duct атрезия носослезного канала отверстие носослезного канала слезная железа воспаление слезной железы, дакриоаденит слезная точка выворот слезной точки сужение слезной точки слезное озеро слезный каналец слезный мешок слезный сосочек слезовыделение избыточное слезовыделение отсутствие слезовыделения слезоотводящие пути слезотечение atresia of nasolacrimal duct orifice/opening of nasolacrimal duct lacrimal gland lacrimal gland inflammation/infection, dacryoadenitis lacrimal point/opening lacrimal opening eversion lacrimal opening stricture lacrimal lake lacrimal duct lacrimal sac lacrimal papilla lacrimation, tearing excessive tearing lack/absence of tears lacrimal ducts/tracts running eyes, epiphora, watery eyes, eyewatering to probe lacrimal ducts зондировать слезопроводящие 19 пути промывать слезные пути расширять слезную точку СЛЕЗНЫЙ КАНАЛЕЦ воспаление слезного канальца непроходимость слезного канальца сужение слезного канальца СЛЕЗНЫЙ МЕШОК воспаление слезного мешка, дакриоцистит водянка слезного мешка свищ слезного мешка флегмона слезного мешка, ДАКРИОЦИСТИТ острый дакриоцистит, флегмона слезного мешка хронический дакриоцистит дакриоцистит новорожденных to wash out/bathe lacrimal ducts to widen the lacrimal opening LACRIMAL DUCT lacrimal duct inflammation lacrimal duct obstruction lacrimal duct stricture/narrowing LACRIMAL SAC lacrimal sac inflammation, dacryocystitis lacrimal sac dropsy lacrimal sac fistula lacrimal sac phlegmon, DACRYOCYSTITIS acute dacryocystitis, lacrimal sac phlegmon chronic dacryocystitis dacryocystitis of the newborn IV. EXAMINATION OF A PATIENT WITH STRABISMUS Anamnesis: 1. The beginning of the disease. 2. The reasons of the disease. 3. Previous diseases of eyes. Physical examination: 1. External examination of eyes. 2. Examination of visual acuity: a) without correction; b) with correction (in eyeglasses or with necessary correction). 3. Examination of clinical refraction by objective method (by skiascopy, by refractometry, by ophthalmometry). 4. Examination of the vision type: 20 a) by colour devices or polaroid. b) with aide of prism. c) by adjusting movement of eyes. 5. Examination of eye movements. 6. Examination of squint angle: a) following the method of Hyrchberg; b) using synoptophore; c) using perimeter; 7. Examination of refracting medium of the eyes and the eye fundus. 8. Diagnose. Plan of therapy. 1. Optic correction of ametropia (after examination of refraction eyes using the cycloplegia). 2. Therapy of amblyopia; a) method of direct occlusion; b) method of negative successive images (at BO); c) method of local blinding irritation by light of optic pit ( at BO). 3. Preoperative orthoptic exercises for rehabilitation of binocular vision: a) using the synoptophore; b) using the stereoscope; c) reading with the grate; d) stereoscopic exercises; e) exercises with prisms; f) exercises for development of eye movement. 4. Operation on oculomotor muscles. 5. Postoperative orthoptic exercises (a, b, c, d, e, f). Practical skills: 1. To determine visual acuity without correction and with correction. 2. To examine refraction by objective methods, skiascopy, and, if possible, by refractometry, and ophthalmometry. 21 3. To adjust glasses to child with squint. 4. To determine the pupillate distance. 5. To examine the vision type: a) using colour devices. b) using the polaroid. c) using the prism. d) by the adjusting movement of eyes. 6. To examine eyeballs mobility. 7. To examine of primary and secondary deviation angles. 8. To differentiate concomitant squint from paralytic. 9. To examine of squint angle using by Hyrchberg’s method, using synoptophore and perimeter. 10. To differentiate accommodative squint from unaccommodative one. 11. To learn the direct occlusion of amblyopia with correct fixation during therapy. 12. To learn therapeutic principles of amblyopia with anomalous fixation. 13. To learn the therapy scheme in general types of squint. 14. To learn the optimal dates of squint therapy. Термины по теме – The terms on the theme КОСОГЛАЗИЕ, СТРАБИЗМ ГЕТЕРОТРОПИЯ, SQUINT, HETEROTROPIA, STRABISMUS аккомодационное косоглазие альтернирующее косоглазие вертикальное косоглазие горизонтальное косоглазие двустороннее косоглазие мнимое/кажущееся косоглазие, псевдострабизм одностороннее/монолатеральное /монокулярное косоглазие 22 accomodation squint/strabismus alternating squint/strabismus vertical squint/strabismus horizontal squint/strabismus bilateral strabismus sham/apparent strabismus, pseudostrabismus unilateral/monolateral strabismus паралитическое косоглазие периодическое косоглазие расходящееся/дивергирующее/ наружное косоглазие, экзотропия скрытое косоглазие, гетерофория содружественное косоглазие сходящееся/внутреннее/конвергирующее косоглазие фиксированное/постоянное косоглазие явное косоглазие косоглазие кверху, гипертропия, суправергенция косоглазие книзу, гипотропия, инфравергенция угол косоглазия, величина, отклонения глаза НИСТАГМ бинокулярный нистагм вертикальный нистагм вестибулярный нистагм вращательный нистагм горизонтальный нистагм диагональный нистагм диссоциированный нистагм интенционный/установочный нистагм крупноразмашистый нистагм лабиринтный нистагм маятникообразный/качательный нистагм мелкоразмашистый нистагм монокулярный нистагм оптический нистагм оптокинетический/зрительный 23 paralytic squint periodical squint/strabismus divergent/external squint, exotropia latent squint, heterophoria concomitant squint convergent/internal squint fixed/constant squint/strabismus apparent/manifest squint upward squint, hypertropia, supravergence downward squint, hypotropia, infravergence angle of squint, eye deviation, value NYSTAGMUS binocular nystagmus vertical nystagmus vestibular nystagmus rotatory nystagmus horizontal nystagmus diagonal nystagmus dissociated nystagmus intention/adaptive nystagmus large-swinging nystagmus labyrinthine nystagmus pendular/rocking nystagmus small-swinging nystagmus monocular nystagmus optic nystagmus optokinetk/optkokinetk/ visual нистагм послевращательный нистагм, постнистагм прессорный нистагм пульсирующий/ретракторный нистагм ротаторный нистагм содружественный/ассоциирован ный нистагм смешанный нистагм спонтанный нистагм среднеразмашистый нистагм толчкообразный/клонический нистагм тонический нистагм нистагм положения nystagmus postrotatory nystagmus, post-nystagmus pressure nystagmus pulsating, throbbing/retractor nystagmus rotatory nystagmus conjugated/associated nystagmus mixed nystagmus spontaneous nystagmus middle-swinging nystagmus jerk/clonk nystagmus tonic nystagmus posture nystagmus V. EXAMINATION OF A PATIENT WITH DISEASES OF THE CONJUNCTIVA The most common type of the illness of conjunctiva is inflammations the most common type of inflammation is infectious conjunctivitises. Basic signs of acute conjunctivitis are redening of eyes, discharge of mucus and pus from conjuctival sac. Besides of it, patients complane of sharp, burning pain, gritty feeling in the eyes, pronounced sensitivy to light, eyewatering, agglutination of eyelashes in the morning by dry ejesta. Anamnesis: The probable cause of the illness should be ascertained: clogging of eyes, adverse conditions of production, contact with patient, contamination in baths, swimming baths, and ect. Physical examination: External changes of eyesin the case of conjuctivitis (redening of eyes, discharge from them, photofobia, and 24 ect.) are noticeable at distance and it is easy to diagnose conjuctivitis. To avoid diagnostic mistakes, it is necessary to determine the sort of hyperemia which should be differentiated in this case from other, peculiar to different more serious illnesses, types of reddening (pericorneal, mixed, episcleral, stagnant injection). The examination of the conjunctiva can be started with examination of its bulbar part. To do it, the patient should be asked to look from side to side with wide-open eyes. Constricted eye-slit, oedema and reddening of eyelids, inflammation, discharges of eyes, maceration of skin can be noticed during an external examination. Some external signs allow to assume the aetiology of illness. For example, reddening and maceration of skin at the corners of the eyes are characteristic signs of the subacute angular conjunctivitis of Morax-Axanfald. Plentiful pus discharge is most frequent in vulgar infection; thick plentiful creamy pus is typical for gonorrheal conjunctivitis. Eruptions on the eyelids or lips follow herpetic conjunctivitis. The great diagnostic importance has examination of eyelids conjunctiva, upper and lower transitional folds. Soft or whitish fibrinogenous pellicles, which are easily strippable by a humid cotton wool, are usually observed by pneumococcal conjunctivitis. Tight united necrotic pellicles make us think of diphtheritic conjunctivitis. Plentiful eruption of follicles on the conjunctiva may be a symptom of allergic conjunctivitis, in particular, medicinal conjunctivitis, as well as, virus conjunctivitis. By adenovirus conjunctivitis, follicles are big, limpid, mainly located at mucous tunic, or lower transitional pleat. The adenovirus conjunctivitis always proceed on the background of respiratory virus infection followed by nasopharyngitis. Discharge is mucus or mucopurulent. It is most important to diagnose acute epidemic conjunctivitis. The highly contagious character of the acute epidemic conjunctivitis should be taken into account. Therefore, prophilactic measures should be undertaken by the examination of the patients. The disease is characterized by several specific signs. A headache, indisposition, and 25 sometimes a fever can precede the illness. Plentiful eruption of follicles is accompanied by submaxillary and aural lymphadenopathy. Discharge is mucus and not abundant. A week after the onset of the conjunctivitis, plural punctulated subepithelial infiltrations appear at cornea and that becomes apparent by a reinforcement of photophobia, eyewatering and a gritty feeling in the eyes (“corneal syndrome”). As a rule, the illness has an epidemic character. Paratrachoma and trachoma cause an appearance of plenty follicles, mainly at upper transitional pleat, but, in Russia, trachoma has been completely liquidated as epidemic disease and its acute stage does not occur. Epithelial papillary can be seen on the gristly part of the upper eyelid conjunctiva. It is a typical sign of spring catarrh. Aged patients often come with complaints of accretion growing at eye. This is vascularized pellicle, that crawls over cornea from internal side. This is pterygium. Practical skills: 1. To drop a drug solution in an eye. 2. To place some ointment. 3. To evert the upper lid. 4. To wash out the conjunctival sac. 5. To dye the margins of the lids. 6. To massage the eyelids by a glass rod. Situation tasks: Diseases of conjunctiva. 1. A 25-year-old patient complains of purulent discharge from the eyes. The disease began three days ago with redness, burning and a gritty sensation. On examination: the eye slits are constricted, profuse mucous-purulent discharge is present. The palpebral conjunctiva is hyperemic, thick and loose. There is purulent secree in the conjunctival capacity. 26 Make up a plan of further examination and treatment. 2. A patient complains of redness of the eyes, a burning sensation and mucous discharge. The disease appeared against a background of ARD with high temperature, evident nasopharyngitis, enlargement of the submaxillary and admaxillary glands. On examination: the palpebral conjunctiva and the sclera are sharply hyperemic, edematic. There are a lot of semitransparent follicles, mainly on the lower transition fold. Form a presumptive diagnosis and make up a plan of treatment. 3. A mother came to a doctor with her 3 year-old child. The child’s left eye turned red and began to suppurate two days before and the same symptoms appeared in the right eye that day. On examination: insignificant edema of the eyelids and the eyeball, the eyelashes are sticked together with purulent discharge. There is sharp hyperemia of the eyelids and the eyeball. Thin whitish films, which are easily removed with a moist cotton ball, are present on the conjunctiva of the lower eyelid. Make a presumptive diagnosis and a plan of further examination and treatment. 4. Full-blown redness and edema of the eyelids appeared in a child on the 3d day after his birth. It is impossible to open the swollen purple eyelids for examination. The eye slit is discharging inchor. Form a diagnosis and plan of further actions. 5. A 3-year-old child fell ill with high temperature, headache and sore throat. On external examination: there is severe edema, hyperemia and induration of the eyelids, which margins are covered with unremovable grey films. Make a presumptive diagnosis and a plan of further actions. 27 6. A patient complains of photophobia, watering and a sensation of sand in the eyes. A week ago he had general weakness, headache, slight fever, painful swallowing, burning pain in the eyes. On examination: hyperemia of the pharynx, enlargement of the submaxillary glands, sharp redness of all sections of the conjunctiva, numerous small follicles in the transition folds. Make a presumptive diagnosis and administer treatment. 7. A 18-year-old boy periodically has photophobia, watering, itchiness and a sensation of a foreign body behind the eyelids, mainly in spring and summer. Examination shows: the conjunctiva of the cartilage of the upper eyelids is of milky color and is covered with numerous big flat pale pink papillary formations, giving the conjunctiva a granular appearance of a “cobblestone pavement”. Make a diagnosis and a plan of actions. 8. A 30-year-old patient came to a doctor complaining of photophobia, watering and a sensation of a foreign body in the right eye. On examination: Vis OD=0.9, conjunctival injection, mucous discharge from the conjunctival cavity, small transparent follicles on the lower and upper transition folds, vitreous edema of the bulbar conjunctiva. The cornea is intact. The patient was administered treatment but in a week he came to the doctor again on account of decrease in vision. Repeated examination showed: oval, coin-like, subepithalial infiltrates appeared on the cornea whereas the conjunctival pattern remained the same. The corneal sensitivity is decreased. Make an etiological diagnosis and administer treatment. 9. A granular sensation, redness and mucous-purulent discharge from both eyes have troubled a patient for several months. The external examination shows: a slight edema of the upper eyelids, the palpebral conjunctiva is thick, loose, hyperemic. There are a lot of big grey yellow 28 jelly-like follicles on the conjunctiva of the upper eyelid, especially in the upper transition fold. The upper section of the cornea is clouding, infiltrated and vascularized. Form a diagnosis and a plan of further actions. 10. Cicatrical changes in the palpebral conjunctiva without any signs of inflammation were revealed during clinical examination of a patient. What diseases might the patient have suffered from? What would you undertake in such cases? 11. During out-patient reception hours a student complains of a sensation of a foreign body in both eyes, slight photophobia, itchiness and rapid blinking. The disease appears every spring during three years. Examination shows: the eyelids are slightly constricted, the eyeballs are hyperemic and excessively moistened. The conjunctiva of the cartilage of the upper eyelid is of milky whitish color, covered with large flat papillomatous formations. Other sections are unaltered. Make a diagnosis and administer treatment. 12. A pupil, having returned from a camp, complains of decrease in vision and photophobia. Ten days ago many children in his group had pain in the eyes, redness, a gritty sensation and watering with mucouspurulent discharge. Some of them had indisposition, swelling and painfulness of the submaxillary and admaxillary glands. According to administrations of a doctor all ill children were given drugs, local treatment and sent home. Examination of the pupil shows: Vis OD=0.6 correction not accepted OS=0.4 correction not accepted The eye slits are constricted because of photophobia. There is moderate watering, numerous transparent follicles on the palpebral conjunctiva, hyperemia of the eyeballs. The cornea is filled with punctated opacities; its sensitivity is decreased. Formulate a diagnosis and make up a plan of further actions. 29 13. A 40-year-old patient came to an oculist with complaints of redness of the right eye, watering, photophobia and a sensation of a foreign body. Examination showed: Vis OD=0.9 / Vis OS =1.0 There was conjunctival injection, mucous discharge from the conjunctival cavity, small follicles on the lower and upper transition folds and the palpebral conjunctiva, vitreous edema of the bulbar conjunctiva. The cornea was intact. Treatment was administered. In a week vision of this eye decreased. Vis OD=0.2 correction not accepted Vis OS=1.0 E Numerous small oval subepithelial infiltrates appeared on the cornea whereas the conjunctival pattern was unaltered. The corneal sensitivity was decreased. Make an etiological diagnosis. Administer treatment. 14. A 19-year-old patient complains of burning pain and purulent discharge from both eyes. Her right eye began to hurt a day ago and her left eye – three days ago. On examination: edema, redness of the eyelids and profuse purulent discharge are obvious even at a distance. The eyelashes are sticked together with pus. There is creamy pus on the skin of the lower eyelids and cheeks. The conjunctiva is sharply hyperemic and thick with pus in the lower arch. Make a presumptive diagnosis and a plan of further actions. 15. A 50- year-old patient complains of redness of the eyes and a gritty sensation. Her eyes have been hurt for several years. On examination: entropion of the lower eyelids, incorrect growth of the eye lashes, cicatrical changes of the palpebral conjunctiva. The transition folds are thick, loose and hyperemic. The lower one third of the cornea is clouding, profusely vascularized. Formulate a diagnosis and administer treatment. 30 Термины по теме – The terms on the theme КОНЪЮНКТИВИТ CONJUNCTIVITIS аденовирусный конъюнктивит аллергический конъюнктивит adenovirus conjunctivitis allergic conjunctivitis ангулярный конъюнктивит angular conjunctivitis блефароконъюнктивит blepharoconjunctivitis spring conjunctivitis/catarrh весенний конъюнктивит/ катар virus conjunctivitis вирусный конъюнктивит herpetic conjunctivitis герпетический конъюнктивит purulent conjunctivitis гнойный конъюнктивит gonorrheal conjunctivitis гонорейный конъюнктивит diphtheritic conjunctivitis, дифтерийный конъюнктивит, ocular diphtheria, diphtheria of the дифтерия глаза eye катаральный конъюнктивит catarrhal conjunctivitis коревой конъюнктивит measles conjunctivitis острый конъюнктивит acute conjunctivitis острый эпидемический конъюнк- acute epidemic conjunctivitis тивит membranous conjunctivitis пленчатый конъюнктивит pneumococcal conjunctivitis пневмококковый конъюнктивит allergic conjunctivitis сенной конъюнктивит staphylococcal conjunctivitis стафилококковый конъюнктивит streptococcal conjunctivitis стрептококковый конъюнктивит trachoma-like conjunctivitis трахомоподобный конъюнктивит phlyctenular conjunctivitis фликтенулезный конъюнктивит follicular conjunctivitis фолликулярный конъюнктивит chronic conjunctivitis хронический конъюнктивит infantile conjunctivitis конъюнктивит новорожденных inclusion conjunctivitis, granular конъюнктивит с включениями, conjunctivitis, paratrachoma, паратрахома, банный/ бассейный bath/pool conjunctivitis конъюнктивит ocular pemphigus пемфигус/пузырчатка глаза snow blindness снежная слепота electrophthalmia электрофтальмия 31 VI. EXAMINATION OF A PATIENT WITH KERATITIS Typical complaints are photophobia, eyewatering, a sensation of a foreign body present, eye-slit is pared-down, falling vision. Anamnesis: 1. Onset of disease. 2. Supposed causes (supercooling, superheating, hit of a foreign body in eye, work in dust-laden premise, as a result of suffering diseases). 3. Similar illnesses in the past. 4. Previous pathologic processes in the organism. 5. Heredity. 6. Previous examination and treatment Physical examination: 1. Examination of acuity of central vision with and without correction. 2. External examination of eyes. Draw attention to presence and intensity of photophobia, eyewatering and blepharospasm. 4. Method of lateral light: a character of injection of the eyeball, state of the cornea (its surface, presence of infiltration, size and depth of its bedding, form and nature of border). Presence and nature of vascularization. State of anterior chamber, iris, pupil. Taking in account that illness of cornea can be complicated by iritis and iridocyclitis, it is necessary to pay attention to the signs of this illness. 5. Determination of corneal perceptibility. 6. Determination of defect of corneal tissue by dye-stuff solutions. 7. Biomicroscopy of cornea. 8. Method of passing light: quickly determine the clarity of deep refracting mediums of eyes (crystalline lens, and vitreous body) in the passing light. When a diagnosis is determined, you should think over a plan of therapy. 32 Practical skills: 1. To drop a drug solution in an eye, placing some salve behind eyelids. 2. To paint the cornea. 3. To put on a monocular and binocular bandage. 4. To determine of defects of cornea by method of dyeing by solution of fluorescein or methylene-blue. 5. To determine of perceptibility of cornea by a fine wisp of cotton, hair method, algesimeter. 6. To take a swab from a corneal ulcer. 7. To learn injection technique of a drug under conjunctiva and physiotherapy methods of treatment. Situation tasks: Corneal diseases. 1. A 20-year-old patient is admitted to the hospital with complaints of sharp photophobia and decrease in vision, which appeared after the eye was contused by a branch of a tree. Vis OD=0.01 correction not accepted. Paracentraly in the cornea there is a greyish yellowish infiltrate with a defect in the center. One margin of the defect is elevated, the other one is flat. Hypopion. The iris is hyperemic, its pattern is vague. The pupil has an irregular form. Formulate a diagnosis, make up a plan of investigation and treatment. 2. After a foreign body had been removed from the cornea the right eye began to trouble a patient. His vision decreased. During investigation: Vis OD=0.02, correction not accepted. Evident mixed injection. In the cornea there is a large purulent sore with purulent infiltrated bottom and margins. In the center of the sore there is a transparent formation in a form of a bleb. Hypopion. The pattern of the iris is vague. The pupil has an irregular form. Make a presumptive diagnosis and a plan of treatment. 33 3. A patient has had troubles with the right eye for two weeks. She complains of visual impairment, photophobia, blepharospasm, watering. Vis OD=0.06, correction not accepted. There is an evident mixed injection. In the corner of the right eye, against a background of diffused infiltration there are two big infiltrates with dendraformed branchy vessels coming to them in the medium layers of the cornea. Make a presumptive diagnosis and a plan of investigation and treatment. 4. A 27-year-old patient got a trauma of the left eye with dry grass during haymaking. Photophobia, watering, a sensation of a foreign body appeared in the eye. The next day pain increased, vision significantly reduced. The patient had severe redness of the eye and clouding of the cornea. During examination: Vis OS=0.01, correction not accepted. The eyelids are slightly edematic, blepharospasm, watering, photophobia, mixed injection of the eyeball. The cornea is edematic, its lower-external section is filled with a dirty yellow infiltrate 5x5 in its size with loose margins and disintegration in the center. There is pus in the anterior chamber. Make an etiological diagnosis and administer conservative treatment. 5. A 21-year-old patient came to an oculist with complaints of a sensation of a foreign body, redness of the right eye, rapid decrease in vision of this eye. A week before after bathing in cold water the patient had had a cold with rash on the skin of the upper lip. Examination showed: Vis OD=0.1, watering, photophobia, constriction of the eye slit, perecorneal injection of the eyeball. A superficial infiltrate in a form of a branch was present in the central section of the cornea. What additional investigations should be carried out to make up a more exact diagnosis? Formulate a presumptive diagnosis and administer treatment. 34 6. A 30-year-old patient came to an oculist with complains of redness of the right eye, watering, photophobia, a sensation of a foreign body. During examination: Vis OD=0.9, conjunctival injection, mucous discharge from the conjunctival cavity, small follicles on the lower and upper transition folds and the palpebral conjunctiva, vitreous edema of the bulbar conjunctiva. The cornea was intact. The oculist administered treatment. In a week vision of this eye decreased. Examination showed: numerous coin-like subepithelial infiltrates appeared on the cornea whereas the conjuctival pattern remained unaltered. The corneal sensitivity was decreased. Make an etiological diagnosis and administer treatment. 7. A 9-year-old child came to on oculist with complaints of decrease in vision and slight redness of the eye, which had appeared 1.5 months before. He had been given a local treatment at the policlinic. During examination: Vis OD-0.1, correction not accepted. Feebly marked perecorneal injection. Clouding in the medium and deep corneal layers with vascular ingrowth. The corneal sensitivity is not changed. The child’s hearing is decreased. What disease can be supposed? What diseases it should be differentiated from? Administer treatment. 8. A 35-year-old patient came to an oculist with complaints of decrease in vision of the right eye. He had got a third-degree burn with sulfuric acid five years before. Examination showed: Vis=1/ ∞ p. l. c. The eye was calm, contraction of the lower arch (adhesion of the palpebral conjunctiva and the bulbar conjunctiva), the cornea was totally clouding, shining, smooth, vasculirized. Make a diagnosis and administer treatment. 35 9. A 21-year-old patient came to an oculist with complaints of pain in the right eye, decrease in vision, photophobia, watering, redness of the eye. Four days before emery got into the eye when he was sharpening a tool. The foreign body was removed immediately and local treatment was administered. But the eye didn’t make recovery. It began to hurt, vision sharply decreased. Earlier the patient had had constant watering and purulent discharge from this eye for one year. Vis OS=0.02, correction not accepted. During examination: watering, photophobia, evident mixed injection of the eyeball. A dirty infiltrate 5 mm in its size with disintegration in the center is present on the cornea. The pupil is constricted. There is pus in the anterior chamber. The iris is green, its pattern is vague. Make a diagnosis. What investigations should be carried out to detect ethiology of the disease? Administer treatment. 10. A 18-year-old patient complains of pain, a sensation of a foreign body, watering, redness of the left eye, decrease in vision. The symptoms appeared three days ago. The patient had AVD with rash on the lip a week ago. Examination shows: watering, photophobia, blepharospasm, perecorneal injection of the eyeball. In the central cornea section there is a shallow infiltrate of incorrect branchy form, it becomes painted when fluorescein is put into the eye. The cornea sensitivity is decreased. What additional investigations should be carried out? Make a diagnosis and administer treatment. 11. A 17-year-old patient complains of photophobia, gradual decrease in vision of the left eye. Examination shows: slight photophobia, constriction of the eye slit, perecorneal injection. The eyeballs are excessively moistened with tears. The corneal surface is rough (resembles shagreen leather). There is diffusive clouding of the deep corneal folds with new vessels in a form of brushes. 36 What disease can you suppose? Make up a plan of general examination of the patient. What additional investigations should be carried out? 12. Sharp photophobia, watering, edema of the right eye and decrease in vision has troubled a 3-year-old child for a week. Examination shows: Vis OD=0.1 the correction not accepted. OD: sharp photophobia, constriction of the eye slit, difficulty in opening the eyelids because of blepharospasm. The eyeball is with evident mixed injection, mainly in the internal section. On the iris, at the limb, at 2, 4, 5, 6 o’clock there are several obtrusive round infiltrates 1-2 mm in their size with vessels coming to them. Other changes haven’t been revealed. Make a diagnosis and a plan of investigation and treatment. Термины по теме – The terms on the theme Кератит авитаминозный кератит аллергический кератит бактериальный кератит бессосудистый кератит герпетический кератит глубокий кератит грибковый кератит, кератомикоз дисковидный кератит диффузный кератит древовидный кератит интерстициальный/паренхиматоз ный кератит Keratitis aritaminotic keratitis allergic keratitis bacterial keratitis nonvascular keratitis htrpetic keratitis deep keratitis mycotic keratitis, keratomycosis diskform keratitis diffuse keratitis dendriform keratitis interstitial/parenchymatous keratitis лучевой кератит поверхностный кератит поверхностный краевой кератит полосчатый кератит пучковидный кератит, блуждаю- radiation/stellate keratitis shallow/superficial keratitis superficial marginal keratitis strip keratitis fascicular keratitis, wandering/travelling phlyctena 37 щая/странствующая фликтена сифилитический кератит сухой/нитчатый/филаментозный кератит, сухой кератоконъюнктивит точечный кератит травматический кератит туберкулезный кератит фликтенулезный/скрофулезный/ туберкулезно-аллергический кератит центральный кератит язвенный кератит, язва роговицы розацеа-кератит syphilitic keratitis dry/filamentous keratitis, dry keratoconjunctivitis punctate keratitis traumatic keratitis tuberculous keratitis phlyctenular/scrofular/tuberculoaller glc keratitis central keratitis ulcerative keratitis, corneal ulcer rosacea keratitis VII. EXAMINATION OF A PATIENT WITH IRIDOCYCLITIS The most typical complaints are severe pain in the eye, photophobia, watering, reddening of an eyeball. Anamnesis: 1. Beginning of the disease. 2. Supposed causes of the disease to the patient’s mind (supercooling, suffering diseases or acute phase of chronic disease). 3. Niduses of a chronic infection. 4. Similar suffed eye illness of the patient or his relatives. 5. Previous examination and treatment. 6. Profession of the patient, conditions of his work. Physical examination: 1. Examination of central visual acuity with and without correction. Irising examination if pupil is dilated by a mydriatic preparation. 38 2. External examination of the eyes. Pay attention to reddening of the eye, presence and intensity of photophobia, eyewatering, heterochromia. 3. Method of lateral light: variety of injection into the eyeball, presence or absence of precipitates on the back surface of the cornea, opacity of liquid of anterior chamber or presence of hypopyon, the iris (colour and pattern), presence of posterior synechiae, status of the pupil (size, form and colour). 4. Method of passing light: you should evaluate the clarity of deep refracting medium of the eyes (opacity of the posterior capsule of the crystalline lens, dimness of other parts of crystalline lens, opacity of vitreous body). It is necessary to differentiate opacity of crystalline lens from that of vitreous body. 5. Palpating the eyeball in the region of projection of ciliary body, you should determine presence of ciliary morbidity and intraocular pressure. 6. To diagnose iridocyclitis, it is necessary to take into account general status of the patient (he must be examined by a phthisiatrician, rheumatologist, rontgenologist, otolaryngologist, dentist, neuropathologist, therapeutist, venereologist) and results of laboratory tests (blood count, Wassermann test, brucellosis tests, toxoplasmosis, rheumatism). 7. When the diagnosis of iridocyclitis is proved you should think over a plan of therapy. The shedule of treatment for iridocyclitis should include: a) a complex of urgent local and general measures by iridocyclitis. Remember, that myotic preparation are contra-indicated by iridocyclitis! b) Etiotropic treatment. c) Nonspecific treatment (antiinflammatory, desensibilizating, absorbing, revulsive and osmotic preparations, elimination of pain, and dilation of the pupil). Illness of the posterior part of the vascular tract (choroiditis) have different clinical presentations. They have painless clinical course. The 39 most typical troubles of patients are disturbance of vision: failing sight, photopsy, metamorphopsia, scotoma, disturbance of twilight vision. The diagnosis of choroiditis are based on methods of ophthalmoscopy, diaphanoscopy, ultrasonic biometrics. In the similar troubles, you should not forget about the possibility of the choroid tumors. Practical skills: 1. To put by an eye dropper, placing a salve behind eyelids. 2. To put on a monocular and binocular bandage. 3. To measure intraocular pressure by palpation. 4. To determine of ciliary morbidity of the eyeball. 5. To know physiotherapatic methods of treatment of illness of vascular tract. 6. To know injection technique of medical product subconjunctivaly and near bulbarly. 7. To know methods of diaphanoscopy, echo-ophthalmography. Situation tasks: Diseases of the uveal tract. 1. A 18-year-old patient has been suffering from rheumatism for several years. Her right eye began to trouble her a week ago. Redness and dull pain appeared. Vis OD=0.8, correction not accepted. There is evident mixed injection. On the posterior corneal surface there are a lot of small whitish precipitates. Descemet’s membrane is folded. The iris is hyperemic and has a vague pattern. The pupil has an irregular form. Pigmentary precipitates are present. Form a diagnosis and a plan of investigation and treatment. 2. A 20-year-old patient is admitted to the hospital with complaints of sharp pain and decrease in vision of the right eye. Vis OD=0.6, correction not accepted. 40 The eye is irritated. Evident mixed injection is present. There are precipitates on the posteria cornea surface, some of them are big and tallowy. The iris is green with a vague pattern. There are a lot of posterior synechiae. Make a presumptive diagnosis, a plan of investigation and administer treatment. 3. A 42-year-old patient came to an oculist with complaints of progressive decrease in vision and pain in the right eye. The patient has periodical redness of the eye. Vis OD=0.1, correction not accepted. Vis OS=1.0 OD: moderate photophobia, pericorneal injection of the eyeball. The cornea is slightly edematic with tallowy precipitates on its posterior surface. The depth of the anterior chamber is not uniform. The pupil is constricted with a circular posterior synechia along its borders. The iris is swollen out toward the anterior chamber (bulging). A reflex from the eye fundus is decreased. Intraocular pressure – T=2 (on palpation). Formulate a diagnosis, administer treatment. 4. A 28-year-old patient has been suffering from rheumatism for several years. Decrease in vision, dull pain in the right eye, redness and photophobia appeared after supercooling a week ago. During examination: Vis OD=0.6, correction not accepted Vis OS=1.0 The right eye: photophobia, evident mixed injection of the eyeball, edema of the posterior corneal sections (folds of Descemet’s membrane). Numerous small precipitates are present on the posterior surface of the cornea. The humor of the anterior chamber is slightly opalescent. The iris is green, its pattern is vague. The pupil is constricted with a gelatinoid exudate. On palpation the eyeball hurts in the area of the cilliary body. 41 Make a diagnosis and a plan of clinical-laboratory investigation. Administer treatment. 5. A 20-year-old patient came to the policlinic with complaints of sharp decrease in vision, moving flakes in front of the right eye, redness of the eyeball and pain in it. The patient had fallen ill two days before after he had suffered from ARD. Examination showed: VisOD=0.1, correction not accepted/Vis OS=1.0 The right eye: there is photophobia, moderate edema of the eyelids, evident redness of the eyeball near the cornea. The cornea is slightly edematic with numerous precipitates on its internal surface. The iris is green with a vague pattern. The pupil is constricted and has an indefinite form. The eyeball sharply hurts on palpation. Make a diagnosis. How can you explain the complaints of moving flakes in front of the eye? What methods should be used to diagnose the case? Make up a plan of etiological investigation and administer treatment. 6. A 27-year-old patient came to an oculist with complaints of severe pain, redness and decrease in vision of the left eye. The symptoms appeared three days before after supercooling. Examination showed: Vis OD=1.0 Vis Os=0.5, correction not accepted. Intraocular pressure for OD=22 mm Hg, for OS=16 mm Hg. The ocular slit of the left eye is moderately constricted, evident perecorneal injection of the eyeball, sharp painfulness on palpation. With lateral illumination precipitates are seen on the cornea. The humor of the anterior chamber is cloudy. The iris has a vague pattern, its color is darker than in the right eye. The right eye is normal. Make a diagnosis. Administer urgent measures and make up a plan of treatment. 42 7. A 60-year-old patient complains of sudden sharp pain, redness and decrease in vision of the left eye. He fell ill 2 days ago after supercooling. He has been suffering from rheumatism for five years. Vis OD=1.0 Vis OS=0.2, correction not accepted. During examination: the left eye – the eye slit is constricted, the eye is irritated, the cornea is transparent. The anterior chamber is of medium depth, the humor is cloudy. The iris has a vague pattern, its color is changed. The eye fundus is without pathology. Intraocular pressure is 18 mm Hg. The right eye is normal. Formulate a diagnosis. What diseases this case should be differentiated from? Administer treatment. Термины по теме – The terms on the theme ИРИДОЦИКЛИТ герпетический иридоциклит гнойный иридоциклит гонорейный иридоциклит лучевой иридоциклит серозный иридоциклит симпатический иридоциклит, симпатическое воспаление, симпатическая офтальмия фибринозный иридоциклит травматический иридоциклит Радужка воспаление радужки, ирит воспаление радужки и ресничного тела, иридоциклит выпадение радужки гетерохромия радужки меланома радужки отсутствие радужки, аниридия патологическое расслоение радужки, иридошизис, 43 IRIDOCYCLITIS herpetic iridocyclitis p urulent iridocyclitis gonorrheal iridocyclitis radial iridocyclitis serous iridocyclitis sympathetic/sympathic iridocyclitis, sympathetic inflammation, sympathetic ophthalmia fibrinous iridocyclitis traumatic iridocyclitis Iris inflammation of the iris, iritis inflammation of the iris and ciliary body, inflamed iris and ciliary body iridocyclitis prolapse of iris heterochromia of iris melanoma of iris absence of iris, aniridia pathologic stratification of iris иридошизис зрачок кольцо Кайзера-Флейшера пятна Брушфильда Зрачок(чки) активный зрачок вяло реагирующий зрачок искусственный зрачок круглый зрачок неподвижный зрачок неправильный зрачок расширенный зрачок симметричные зрачки суженный зрачок за ращение зрачка расширение зрачка, мидриаз реакция зрачка на свет сращение зрачка средство, расширяющее (суживающее) зрачок сужение зрачка, миоз pupil, pupilla Kayser-Fleischer's ring Brushfield's spots Хориоидея воспаление хориоидеи, хориоидит воспаление радужки и хориоидеи, иридохориоидит Cnoroid, vascular coat of the eye inflammation of choroid, choroiditis inflammation of iris and choroid, iridochoroiditis Хориоидит диссеминированный/рассе-янный хориоидит диффузный хориоидит ограниченный хориоидит очаговый хориоидит периферический хориоидит симпатический хориоидит туберкулезный хориоидит центральный хориоидит экваториальный хориоидит Choroiditis disseminated choroiditis Pupil(s), pupilla (papillae) active pupil sluggish pupil artificial pupil round pupil fixed pupil irregular pupil dilated/mydriatic pupil symmetrical pupils constricted/miotic pupil pupillary constriction pupillary dilation, mydriasis pupillary response to light pupillary adhesion/symphysis mydriatic (miotic) pupillary constriction, miosis 44 diffuse choroiditis limited choroiditis focal choroiditis peripheral choroiditis sympathetic choroiditis tuberculous choroiditis central choroiditis equatorial choroiditis VIII. EXAMINATION OF A PATIENT WITH PATHOLOGY OF THE CRYSTALLINE LENS The most typical complaint is gradual painless decrease of vision. Anamnesis: 1. The initial stage of the disease, its age. 2. Nature of failing vision. 3. Supposed causes of the disease to the patient’s mind. 4. An injury (especially head one) in the past. 5. Concomitant disease of the eyes (glaucoma, shortsightedness, uveitis). 6. Profession of the patient, professional insalubrities. 7. Systemic diseases. 8. Family anamnesis, analogue illness in his relatives. Physical examination: 1. Examination of central visual acuity with and without correction. In the absence of subject vision, you should determine the photoperception. You should note the type of lightprojection. It is necessary to examine the photoperception thoroughly. The visual acuity equaled photoperception with incorrect projection of light or equaled zero is an evidence of lesion of the retina or the optic nerve. This is a contra-indication for cataract extraction. In this case, additional methods of investigation are necessary (echoophthalmometry, diaphanoscopy and others) to avoid retinal detachment, an intraocular tumor, absolute glaucoma etc. 2. External examination of the eyes. You should determine the state of surrounding tissues and supplementary apparatus (including lacrimal sac: presence or absence of discharge from lacrimal points pressing the region of lacrimal sac). 45 3. Method of lateral light: you should determine the state of conjunctiva, sclera, and cornea and the depth of the anterior chamber in comparison with the other eye. You should look at the colour and pattern of the iris, presence of its trembling (iridodonesis), size, form, reaction of the pupil to light; you should draw an especial attention to the pupil colour (black, grey, nacreous, milk-white) and presence the iris shadow and its width. 4. Method of passing light: you should determine the lenticular transparency of the crystalline lens. You should pay attention to the presence of spoke like, punctated, and polymorphous opacity on the fundus in the case of total cataract. For more accurate localization of opacity (the cornea, the different parts of the lens, or vitreous body), you should evaluate the opacity and its motility. 5. Biomicroscopy. You should evaluate lentucular opacity, its depth, presence of vacuole, water slits, and plaques. 6. You should measure intraocular pressure by palpation and tonometer. You should make a preliminary diagnosis basing upon the patient’s complaints, anamnesis, and physical examination. You should differentiate a cataract from an open-angle glaucoma. You should prove your recommendations for the treatment. You should determine a possibility of a surgical treatment and prove the indications for an operation. If the surgical treatment is recommended, it is necessary to performe additional tests (see list of necessary tests for the preparation of the patient for an operation). List of necessary tests preparing a patient for a cataract extraction. Ophthalmoscopy: 1. Acuity of vision, refraction. 2. Tonometry. 3. Method of lateral light. 4. Method of passing light. 5. Biomicroscopy. 46 6. Ultrasonometry. 7. Examination of state of lacrimal ducts. 8. Investigation of microflora of conjunctival sac. General tests: 1. Blood count, blood sugar, Wassermann test. 2. Urine analysis. 3. Feces analysis on helminth eggs. 4. X-ray examination of the chest. 5. Electrocardiogram 6. Certificate of therapeutist about possibility of a surgical operation (absence of contraindications for base on general condition of the patient). 7. Certificate of a dentist about the state of oral cavity, and dental sanation. 8. Certificate of an otolaryngologist. 9. Certificate of a neuropathologist if it is necessary. 10. Certificate of an endocrinologist if it is necessary. Practical skills: 1. To examine visual acuity in failed vision and lack of subject vision (determination of photoperception with correct or incorrect lightprojection). 2. To evaluate opacity of the iris by means of lateral light in the immature cataract, tears of ligaments, aphakia. 3. To evaluate opacity of the lens by means of passing light. There are punctated, polymorphous, and spoke like opacities on pink background. 4. To evaluate the lacrimal ducts pressing the region of lacrimal sac and putting the collargol solution in conjunctival sac by a dropper, and washing out lacrimal ducts. Situation tasks: 47 Cataract 1. Visual acuity of both eyes had been gradually and painlessly decreasing for 2 years in a 62-year-old patient. At first flying midges, polyopia (numerous images of a light source) and then dimness appeared in front of the eyes. What pathology may take place in this case? What investigations should be carried out to make a more exact diagnosis? What treatment would you recommend? 2. A woman with a 3-year-old child came to an oculist. She occasionally noticed small white dots in the papillary centers in the child’s both eyes. The child was developing in accordance with his age. Anemnestic pathologies were absent. During investigation by passing light against a background of pink reflex of the pupil dark dots are seen shifting when the eyeballs were moving. Formulate a diagnosis and give recommendations. 3. A 68-year-old woman who had been wearing reading glasses +3.0 D for many years noticed that she began to read without the glasses well, but her distance vision decreased. Vis OD=0.4-2.5D=1.0 Vis OS=0.4-2.5D=1.0. The eyes were calm. With the focal light and in the passing light no significant changes were revealed. What initial pathological process can be supposed? What additional methods of investigation could help to make a correct diagnosis? 4. A 45-year-old patient came to the policlinic with complaints of significant decrease in vision of both eyes. Vis OD=0.03, correction not accepted Vis OS=0.04, correction not accepted. 48 The visual fields of both eyes are normal. Intraocular pressure in both eyes is 20 mm Hg. Biomacroscopy examination showed the presence of clouding in the posterior capsule, more compact in the center. The reflex from the eye fundus is marked at the periphery. Make a diagnosis and administer treatment. 5. A patient is admitted to the hospital with complaints of absent subject vision of the right eye. Examination shows: the eye is calm, the cornea is transparent, the anterior chamber is shallow. The dilated oval pupil has an irregular form. Local atrophy of the iris is present at 3 o’clock. There is marginal cupping of the optic disk on the eye fundus. Vis OS=1/∞ PLC, intraocular pressure is 36 mm Hg. Gonioscopy shows: the angle is closed by the root of the iris. Make a diagnosis and administer treatment. 6. A 38-year-old employee of a radioisotope therapy laboratory noticed rapid decrease in vision of both eyes. Examination showed: Vis OD=0.02 correction not accepted Vis OS=0.04 correction not accepted. With focal illumination the pupils looked grey. During investigation by passing light clouding of the lens in the posterior coretal layers was present. There was a red reflex at the periphery of the pupillary region. Formulate a diagnosis. Make up a plan of treatment taking into account low visual acuity. Means of further correction. 7. A 23-year-old patient came to an oculist with complaints of progressive painless decrease in vision of the right eye after a blunt cranium trauma. During examination by lateral illumination it was revealed that the pupil of the right eye had a quick reaction to light and the pupillary region was grey. A decreased pink reflex was seen in the passing light. 49 Formulate a diagnosis, give recommendations and administer treatment. 8. A 30-year-old patient complains of gradual painless decrease in vision of both eyes. During investigation by biomicroscopia it is revealed that clouding in the cortical layers of the lens in a form of small grey spots and vacuoles are present. The patient has been suffering from diabetes for 12 years. The sugar level in blood is unsteady. The patient breaks insulin dosage regimen. Make a diagnosis and give recommendations. 9. A 17-year-old patient complains of low visual acuity of the left eye. Examination shows: Vis OD=1.0 Vis OS=0.02+10.0 D=1.0. During investigation by lateral illumination: OS – the anterior chamber is deep, the iris is trembling, the pupillary region is of black color. In the passing light a pink reflex is seen. A half of a year ago the patient received a blunt trauma of the left eye after which vision sharply decreased. The patient didn’t come to an oculist then. Formulate a diagnosis and give recommendations. 10. A 60-year-old patient being at a therapeutics department with severe diabetes lost vision of the right eye. Visual acuity of both eyes had been sharply decreasing during last year. Glasses didn’t help anymore. Vis OD=1/∞ pr.l.c. Vis OS=0.06, correction not accepted. No pathology was revealed in the anterior sections of both eyes. A reflex from the fundus of the right eye was absent. The fundus of the left eye was clearly seen. Dilation and twisting of the veins, numerous microaneurysms, small hemorrhages and cotton-like focuses were observed. 50 Make a diagnosis and a plan of treatment. 11. A 68-year-old patient came to an oculist with complaints of slow painless decrease in distance vision forseveral years. Examination showed: Vis OD=0.2, correction not accepted, refraction – E. Vis OS=0.3, correction not accepted, refraction – E. The eyes were calm, the anterior section was unaltered. What disease can you suppose? Make up a plan of further investigations to diagnose the case. 12. A 75-year-old patient came to an oculist with complaints of progressive painless decrease in vision of both eyes for two years. There was no pain and redness in the eyes. During examination: Vis OD=0.04, correction not accepted Vis OS= 1/∞ pr.l.c. OD – the eyeball was calm, the cornea was transparent. The anterior chamber was normal. The pupil was of grey-white color with falciform shadow falling from the iris. A reflex from the eye fundus was absent. OS – the eyeball was calm. The cornea was transparent, the anterior chamber was normal. The pupil was of uniform grey color. A reflex from the eye fundus was absent. IOP OD=18 mm Hg, IOP OS=19 mm Hg. Formulate a presumptive diagnosis and make up a plan of investigations and treatment. 13. A 68-year-old patient complains of progressive painless decrease in vision of the right eye for two years. There were no signs of inflammation. Examination shows: Vis OD=0.02, correction not accepted Vis OS=1.0 E. 51 On investigation of the right eye by the method of the lateral illumination it is revealed: the pupil is grey. There is a slight shadow from the iris. In the passing light a red reflex from the eye fundus is absent. The left eye is normal. Make a diagnosis and give recommendations. 14. A bus driver underwent an operation for traumatic cataract a half of a year ago. After that glasses were prescribed to the patient, which increased vision of the left eye to 1.0. At present moment the patient complains of the fact that he can’t use the glasses since vertigo, nausea and diplopia appear when he wear them. During examination: Vis OD=1.0 E Vis OS=0.02+10.0 D=1.0. The right eye is normal. The left eye is calm, the cornea is transparent, the anterior chamber is deep, refractive mediums are clear, iridodonesis is present. The fundus of the eye is normal. Make a diagnosis and indicate the means of professional rehabilitation. 52 Термины по теме – The terms on the theme КАТАРАКТА бурая/черная катаракта веретенообразная катаракта врожденная катаракта вторичная/последовательная катаракта голубая катаракта диабетическая катаракта дисковидная катаракта дырчатая катаракта задняя полярная катаракта звездчатая катаракта, катаракта хрусталикового шва зрелая (незрелая) катаракта корковая/кортикальная катаракта коронарная/венечная катаракта лентикулярнаяя катаракта лучевая катаракта люксированная катаракта медная катаракта, халькоз хрусталика морганиева/молочная катаракта начинающаяся катаракта передняя полярная катаракта перезрелая катаракта перепончатая катаракта пленчатая катаракта порошкообразная ядерная катаракта, катаракта Коппок приобретенная катаракта прогрессирующая катаракта розетчатая катаракта слоистая катаракта старческая катаракта тотальная катаракта травматическая катаракта ядерная катаракта 53 CATARACT brown/black cataract spindle-shaped cataract congenital cataract secondary/successive cataract blue cataract diabetic cataract diskform cataract stenopeic cataract posterior polar cataract stellate cataract, cataract of lenticular raphe mature (immature) cataract cortical cataract coronary/coronal cataract lenticular cataract stllate cataract luxated cataract copper cataract, lenticular chalcosis Morgagni's/lacteal/lacteous cataract arising cataract anterior polar cataract overripe/hypermature cataract membranous cataract membranous cataract powdered nuclear cataract, Coppock's cataract acquired cataract progressive cataract rosella/rosula cataract stratified cataract senile cataract total cataract traumatic cataract nuclear cataract IX. EXAMINATION OF A PATIENT WITH GLAUCOMA Typical complaints of the patient with the closed-angle glaucoma are: 1) periodical opacities (usually in the morning); 2) appearance of rainbow circles in a glance at a source of light; 3) pain in an eye and the same part of the head. 4) nausea, vomiting and the listed signs present in the acute attack of glaucoma. Complaints of a patient by in an acute attack: 1. Severe pain in eye irradiating in the same part of the head, heart region, and abdomen region. 2. Different stages of vision failing. Sometimes blindness. 3. Nausea, sometimes vomiting. Complaints in the case of open-angle glaucoma: slow painless failing of vision. Anamnesis: 1. When the complaints appeared. Supposed causes of the disease (work with lopsided head, excess of consumption of liquid, superheating, stress and so on) 2. Has the patient a medical record because of glaucoma? 3. Treatment applied in the past and actual therapy (regimen of myotic preparations), its effectiveness (subjective feeling of the patient, the state of function of vision, intraocular pressure). Anamnesis of live: 1. Age of the patient (as a rule, after 40). 2. The presence of endocrine and vascular disorders (diabetes, climacteric, diencephalic pathology). 3. The presence of glaucoma in relatives. 4. The presence of professional insalubrities. 5. Long application of corticosteroids. 54 Physical examination: 1. Examination of central visual acuity with correction. 2. Examination of borders of visual fild approximately and with the help of perimeter. 3. By the use of lateral light, you should pay an attention to the possibility of dilation anterior ciliary vessels (“cobra symptom”), the clarity and sensitivity of the cornea, depth of the anterior chamber, the size of the pupil, and the state of the iris. 4. In biomicroscopy, the changes of the front part of eye should be evaluated in details thoroughly (the anterior ciliary vessels, postoperative sutures; coloboma, atrophy of stroma of the iris, size of the pupil and its dystrophy, especially in the people who were treated by miotics and so on). 5. Ophthalmoscopy (usually, it is performed with a teacher): 1) the presence of glaucoma’s exavation coming up to the margin of the optic nerve and accompanied by a curve of vessels. 2) grey colour of the optic disk. 6. Examination of the angle of the anterior chamber: 1) the approximate test following the Vurgaft method. 2) with the help of gonioscope (it should be demonstrated by a teacher). 7. Tonometry: 1) by palpation; 2) with the help of Maklakov tonometer (10g. weight). Additional diagnostic examination are day's tonometry, frequentative tonometry during the day (every 3 hours), elastotonometry, tonography, stress, and unloading tests. The diagnosis of glaucoma should be comprehensive. The type, the stage, the level of ocular tension, dynamics should be evaluated in the both eyes separately. Therapeutic approach You should determine the treatment (writing out a prescription for drops, eye ointment, medicines orally, intramuscularly, intravenously). If an operation is nesessary. You should determine the type of operation. 55 It should be emphasized that mydriatic preparation are contraindicated in iridocyclitis. Practical skills: 1. To determine intraocular pressure by palpation, data recording. 2. To determine intraocular pressure by Maklakov tonometer, data recording. 3. To determine the field of vision by confrontation field testing. 4. To determine the field of vision by perimeter. 5. To carry out biomicroscopy of front part of eye. You should learn examination of the cornea, the depth of the anterior chamber, the iris, and its pigment border. 6. To learn elastotonometry, tonography, gonioscopy, campimetry, 7. To determine of the width of the angle of the anterior chamber by side illumination. Situation tasks: Glaucoma. 1. A patient complains of periodical dimness in front of the right eye and rainbow effects around a source of light in the morning. Vis OD=1.0. The visual field on the nasal side is constricted to 30˚ from the fixation point. The anterior cilliary arteries are dilated. The anterior chamber has small depth and a narrow angle. Initial excavation of the disk is present on the eye fundus. Intraocular pressure is 30 mm Hg. Make a diagnosis. 2. A 48-year-old patient complains of decrease in vision of the left eye, which he occasionally noticed a week ago. Vis OS=0.2, correction not accepted. The anterior chamber is of medium depth, its angle is opened. The pupil with the diameter of 2 mm is sluggish. Evident excavation of the optic nerve is present on the eye fundus. Intraocular pressure is 36 mm Hg. The visual field is constricted to 15˚ around the fixation point. 56 Make a diagnosis. 3. After doing the laundry a 60-year-old woman felt pain in the left half of the head and in the left eye, nausea, vomiting. Her left eye turned red, its vision decreased. Examination showed: Vis OS=0.2, correction not accepted. The eye was red with a blue shade, the cornea was grey-white, opalescent, the epithelium was edematic. The pupil was dilated and grey-green in its color. A reflex from the eye fundus was decreased. T+3. Formulate a diagnosis and administer treatment. 4. A patient came to a doctor with chronic bronchitis and bronchial asthma. On his outpatient card there is a note “Glaucoma”. What drugs used for asthmatic diseases are contradicted to the patient? 5. A 65-year-old woman was admitted to the intensive therapy department for antrioventricular block and rare rhythm of ventricle contraction. The disease was accompanied by diabetes of the fist type and closed-angle glaucoma. What medicaments shouldn’t be used for antrioventricular block in this particular situation? What drugs may substitute them? 6. A 63-year-old blind in both eyes man was directed to an oculist to remove a cataract. The patient said that his right eye hadn’t seen for a half of a year and the left eye became blind three months ago. Vision had been falling slowly and painfully. A doctor diagnosed a cataract that could be removed when the eye would stop seeing. After examination the oculist denied the presence of a cataract and determined that the cause of blindness was glaucoma and operation wouldn’t help. What methods of investigation allowed the oculist to deny cataract and diagnose glaucoma? What form and phase of glaucoma took place in the patient? Why couldn’t the patient be made an operation? What was the doctor’s mistake? 57 Термины по теме – The terms on the theme ГЛАУКОМА врожденная глаукома вторичная глаукома закрытоугольная глаукома застойная глаукома открытоугольная глаукома первичная глаукома приобретенная глаукома простая глаукома травматическая глаукома приступ глаукомы острый приступ глаукомы подострый приступ глаукомы внутриглазное давление, офтальмотонус повышение внутриглазного давления GLAUCOMA congenital glaucoma secondary glaucoma closed-angle glaucoma congestive glaucoma open-angle glaucoma primary glaucoma acquired glaucoma simple glaucoma traumatic glaucoma attack of glaucoma acute attack of glaucoma subacute attack of glaucoma tension of the eye, ocular tension, intraocular pressure, ophthalmotonus elevation in the ocular tension видение радужных кругов rainbow vision, seeing rainbow effects краевая экскавация диска marginal excavation of the optic зрительного нерва disk сужение поля зрения narrowing of visual field margin понизить внутриглазное давление to relieve intraocular pressure X. EXAMINATION OF A PATIENT WITH OCULAR INJURIES Examining patients with a injury of an organ of vision, the type of the injury should be determined first of all. The patient can have a 58 contusion, a wound, or a burn. To do that it is important to know significant and probable signs of perforative injury. A. Characteristics of medical examination of a patient with a penetrating wound of eyes Anamnesis: 1. You should ask what the patient was doing when he got injured. 2. What the material did the patient working with in the time of injury? 3. Were the objects dirty, which were worked with? 4. You should ask the patient could a foreign body get in his eye. Could it be magnetic? 5. The time of the injury and the time of medical aid. 6. What the measures were performed as a first aid? Where was the first aid administered? Physical examination: 1. Examination of visual acuity with and without correction. 2. External examination of eye. 3. Method of lateral light. You should determine the type of injection of the eyeball, the presence of a wound of the cornea, sclera or limb, the presence of adaptation or gaping of the margins of the wound, infiltration of the margins of the wound, incarceration in the wound internal membranes. The state of the anterior chamber (depth, nature of contents), iris (incarceration in the wound, dislocation of the wound, colour of the iris, presence of apertures, defects in the iris), the pupil (size, form, colour) should be examined. The presence of a foreign body can be suspected if there are aperture in the iris, tears of the pupil margins, or limited opacity of the lens. It should be remembered that these signs of a foreign body are relative. To make the detection of intraocular foreign body completely certain, it is necessary to perform rontgenologic examination with the subsequent localization of foreign body in all the patients. 59 In all patients with the penetrating wound, pay attention to signs of incipient infection (infiltration of margins of the wound, precipitates on the back surface of the cornea, muddy moisture of the anterior chamber, pus from the anterior chamber, change of colour of iris). 4. Method of passing light: pay attention to presence of opacities of the lens, floating opacities in vitreous body resulting hemorrhage at its. Floating foreign body in vitreous body a with metallic tint is possible. 5. Ophthalmoscopy: pay attention to a foreign body on the fundus. The foreign body can be visible in ophthalmoscopy. B. Characteristics of examination of a patient with a burn of eyes Anamnesis: 1. You should ask the patient was it a thermal burn or a chemical one. 2. If some chemical substance got into an eye, it is necessary to find out properties of the substance (acid or alkali, other characteristics), its concentration, and quantity of the substance. 3. The time of the burn and the time of the first aid. 4. What the measures were performed as the first aid? Where was the first aid applied? 5. When was the patient sent to the clinic? Physical examination of the eye: 1. Examination of central visual acuity with and without correction. 2. External examination of the eyes. The the eyelids (swell, hyperemia of skin, blistering, presence of necrosis), the conjunctiva (hyperemia, oedema, formation of white pellicles, defects of tissue, necrosis) should be evaluated. The margin of the eyelids, the conjunctiva of the eyeball should be evaluated. Pay attention to examination of the cornea (cornea dimness of different degree, infiltration, necrosis, the presence of defect of tissue). For detection of area and depth of defects of cornea and conjunctiva, you should dye the eye tissue with the 1% solution of fluorescein or 1% water solution of methylene-blue. Burns of eyes can 60 be complicated by iritis, iridocyclitis, secondary glaucoma, and cataract. During the medical examination of the patients, it is necessary to draw attention to the presence of signs these diseases. Practical skills: 1. To determine intraocular pressure by palpation. 2. To put on a monocular and binocular aseptic bandage and plaster bandage. 3. To wash out the conjunctival sac. 4. To remove superficial foreign bodies from conjunctiva and cornea. 5. To localize intraocular foreign bodies by X-ray photograph with the help of Komberg – Baltin scheme. 6. To detect defects of conjunctiva and cornea by method of the dyeing with the 1% solution of fluorescein or 1% water solution of methyleneblue. C. Characteristics of examination of a patient with contusion of organ of vision Anamnesis: 1. Listen to the patient complaints, determine conditions of injury: what object inflicted the injury and what strength was the injury inflicted with? Was the injury inflicted during work or in private life? Note the time of the injury and the time of seek medical advice. If there is a haematoma of the eyelids, you should ask the patient whether the haematoma has appeared immediately after the trauma or after a while. Ask the patient did he lose consciousness. Did the patient is given first aid? What the measures were performed as first aid? Where was the first aid administered? It should be noted if the vaccination with tetanus vaccine was done. If no vaccination was done after the injury, the time of the last vaccination should be asked. Method of passing light allows to determine the traumatic opacities of the lens, floating opacities or partial absence of reflex on the fundus of 61 the eye by partial hemophthalmus, absolute absence of pink reflex on the fundus of the eye by total hemophthalmus. Ophthalmoscopy allows to determine the hemorrhage in the retina, retinal detachment, oedema of the region of yellow spot (opacity of the retina), the rupture of choroid at periphery, course of vascular fascicles on the fundus of the eye. Biomicroscopy allows to work out a detailed diagnosis of thin injuries. You should measure intraocular pressure by palpation because the contusions are often accompanied by hypertension that can transform to the secondary glaucoma, or contrariwise to hypotonia of the eyeball. Rontgenography of an eye-socket and paranasal sinus is performed to determine the integrity of bones. When the diagnosis is proved you should think over a plan of therapy. Situation tasks: Ocular trauma. 1. A 20-year-old patient was admitted to the hospital with complaints of pain, severe irritation and decrease in vision of the right eye, which appeared soon after a contusion of the eye with a branch of a tree. Vis OD=0.01, correction not accepted. Evident mixed injection. Paracentrally in the cornea there is a grey yellowish infiltrate with a defect in the center. One margin of the defect is elevated, the other one is flat. Hypopion. The iris is hyperemic with a vague pattern. The pupil has an irregular form. Make a diagnosis, a plan of investigation and treatment. 2. After a foreign body was removed from the cornea the right eye began to trouble a patient. His vision decreased. During investigation: Vis OD=0.02, correction not accepted. Evident mixed injection. In the cornea there is a large purulent sore with purulent infiltrated bottom and margins. In the center of the sore a transparent 62 formation in a form of a bleb is present. Hypopion. The pattern of the iris is vague. The pupil has an irregular form. Make a presumable diagnosis and a plan of treatment. 3. A 27-year-old patient received a trauma of the left eye with dry grass that resulted in photophobia, watering, a sensation of a foreign body. The next day pain increased, vision significantly decreased. The patient had sharp redness of the eye and a white spot on the cornea. Examination showed: Vis OD=0.01, correction not accepted. The eyelids were slightly edematic. Blephorospasm, watering, photophobia, mixed injection of the eyeball. The cornea was edematic, its lowexternal section was filled with a dirty yellow infiltrate 5x5 mm in its size with disintegration in the center and loose margins. There is pus in the anterior chamber. Formulate a diagnosis and administer treatment. 4. A patient complains of watering, photophobia, blepharospasm, appeared after a microtrauma of the cornea. Examination shows: perecorneal injection of the eyeball, the cornea is edematic. In the center of the cornea there is a pointed infiltrate which is swollen out of the surface. Shining is absent. The corneal surface is painted with fluorescein. Make a diagnosis and administer treatment. 5. A 22-year-old patient came to an oculist with complaints of pain in the right eye, decrease in vision, photophobia, watering and redness of the eye. Four days before emery got into the eye when he was sharpening a tool. The foreign body was removed immediately and local treatment was administered. But the eye didn’t make recovery. It began to hurt, vision sharply decreased. Earlier the patient had had constant watering and purulent discharge from this eye for one year. Vis OS=0.02, correction not accepted. 63 During examination: watering, photophobia, evident mixed injection of the eyeball. A dirty infiltrate 5.5 mm in its size with disintegration in the center was present on the cornea. The pupil was constricted. There was pus in the anterior chamber. The iris was green with a vague pattern. Make an etiological diagnosis. What additional investigations should be carried out to reveal the local pathology? Administer treatment. 6. A 35-year-old patient came to an oculist with complaints of decrease in vision of the right eye. He had got a third-degree burn with sulfuric acid five years before. Examination showed: Vis=1/∞ p. l. c. The eye was calm, contraction of the lower arch (adhesion of the palpebral conjunctiva and the bulbar conjunctiva), the cornea was totally clouding, shining, smooth, vasculirized. Make a diagnosis and administer treatment. 7. A 13-year-old patient is admitted to the hospital with complaints of decrease in vision of the right eye. The eye was hit with a snowball two hours before. During examination: Vis OD=0.1. Hematoma of the eyelids, the eye is calm, the cornea is transparent. There is a 1-mm blood level in the anterior chamber. The pupil 5x4 mm in its size has an irregular form. Mydriasis. The lens is transparent. There is a moving clouding in the anterior chamber of the vitreous body. Form a diagnosis and administer treatment. 8. A 36-year-old patient is admitted to the hospital with complaints of sharp pain in the left eye and decrease in vision. 40 minutes ago splashes of calcimine got into the left eye when the patient was plastering. Examination shows: Vis OD=1,0 OS=0.2, correction not accepted. 64 The skin of the eyelids is edematic. Chemosis. The cornea is cloudy and de-epithalized. The anterior chamber is of medium depth. The iris is edematic. The pupil is 5 mm in its size. A reflex from the eye fundus is decreased, the details are not seen. Formulate a diagnosis and define the volume of the first medical aid. Administer treatment. 9. A 35-year-old patient is admitted to the hospital with complaints of decrease in vision, redness of the right eye and pain in it. The symptoms appeared a week ago without obvious reasons. Three years ago the patient took treatment in the in-patient department on account of severe penetrating corneoscleral trauma in the left eye. After a week’s treatment enucleation of the left eye was offered to the patient, but he refused. Examination shows: Vis OD=0.2, correction not accepted, Vis OS=0. The right eye: perecorneal injection, precipitates on the cornea, the iris is green, the pupil is 2 mm. There is a deposition of fibrin in the lens. A reflex from the fundus of the eye is decreased, the details are not seen. The left eye: calm, diminished in its size, evident hypotonia, the cornea is cloudy with a scar from 12 to 4 o’clock. The anterior chamber is flat, the iris is atrophic. Formulate a diagnosis and administer treatment. 10. A 27-year-old patient received a trauma of the right eye with dry grass. After that redness of the eye, watering, photophobia and decrease in vision appeared. The condition of the eye was getting worse. It became blind and severe pain appeared in it. Vis OD= 1/∞ p.l.in.c. Vis OD=1.0 The right eye: the blue eyelids are dense and edematic. The eye slit is constricted. Exophthalmos, the eyeball is motionless. The edematic conjunctiva is swollen out in a form of a roller and trapped by the eyelids. On the cornea there is a loose clouding with disintegration in the 65 center. The anterior chamber is of medium depth, the iris is of dirty grey color with a green shade. The pupil is yellowish white. A reflex from the eye fundus is absent. There is full-blown painfulness of the eyeball. The patient has weakness, headache and temperature 38˚. Make a diagnosis and administer treatment. 11. A 41-year-old patient is admitted to the ophthalmologic clinic with complaints of sharp decrease in vision and pain in the left eye. Two days ago something got into the left eye when he was working with metal. Next day he noticed decrease in vision, redness of the eye and felt pain in it. During examination: Vis OD=1.0 Vis OS=1/∞ p.l.in.c. Mixed injection, impairment of the conjunctiva in the external sections, the cornea is opalescent, the anterior chamber is of medium depth, the pupil is 3 mm. A reflex from the eye fundus is greenish, T+1. Cilliary pain. Formulate a diagnosis and make up a plan of investigation and treatment. Prognosis. 66 Model of the case history Design of the front page of the case history. State educational institution Higher Professional education Ryazan State I.P.Pavlov Medical University Ministry of Health of the Russian Federation The chair of ophthalmology (the head of the chair, assistant, teacher). History of the patient. Name and Sirname The diagnosis: The mature senile cataract of the right eye, aphakia, secondary membranous cataract of the left eye. Concomitant diseases: The general atherosclerosis, anchylosis of right ankle-joint. The curator: student of 5 year, 12 group, medical department Lisicina G. N. 12 December 2018 year. 67 The passport data: the patient’s name, last name, patronymic, age, the time of admission to hospital. Complaints of the patient (concerned eyes and any other) on the day of medical examination. History of the disease: the development of the disease from its beginning should be described. In the case of an acute condition of chronic disease, the character of the last exacerbation should be described first. The cause of the disease supposed by the patient should be noticed. Mention any illness of eyes has taken place in the past. Circumstances of the injury, mechanism, the time of the injury and the time of the first aid should be noted by the trauma. The treatment of the patient and its efficacy (from day of the first medical examination) should be described. Past history: you should briefly indicate important events of patient life. Every fact which is essential for appearing and development of the actual diseases should be described in details. Suffered diseases and heredity should be noted General examination (organ systems should be described briefly): The state of organ of vision. Vis OD = without correction and then with correction. Vis OS = without correction and then with correction. The right eye: Eyelids: the size and the form of the eye-slit, the position of the eyelids, the skin, margins of the eyelids, growth of the eyelashes. 68 Lacrimal organs: the lachrymal gland, lacrimal points, ducts, lacrimal sac, the ductus and nasal tests, the rontgenography of lacrimal ducts. The palpebral and bulbar conjunctiva: the colour, the state of surface, the clarity, the discharge. The eyeball: the size, the form, the position in the eye-socket, the mobility, the presence or absence of injection and its type. The sclera: the colour, the surface, local infiltration, painful palpation. The cornea: the form, the size, the clarity, the smoothness, the humidity, the luster, the perceptibility, the presence of vessels. The anterior chamber: the depth, the clarity of moisture (liquid). The iris: the colour, the pattern, the pupil (diameter, form, colour, reaction for light, accommodation and convergence), symptom of trembling. The ciliary body: palpatory tenderness of eye at the region of ciliary body. The crystalline lens: the state, the clarity (localization, intensity, form of dimness). The vitreous body: the clarity (type of dimness). The fundus of eye: the optic disk, the state of vessels, the region of yellow spot, marginal parts of the fundus of eye. The field of vision. Intraocular pressure. 69 The left eye: (it should be described in the same consecution) A preliminary diagnosis: Laboratory and other methods of examination: A differential diagnosis: (if necessary, the problems of aetiology and pathogenesis should be discussed). Substantiation of diagnosis: Final clinical diagnosis: Treatment: should be prescribed individually to the patient (as a prescription) If the surgical treatment is necessary, the type of recommended operation should be determined and substantiated. The prognosis of the disease (with respect to vision) : The signature of the curator: Special attention writing the case history should be paid to the differential diagnosis of similar diseases. ТИПИЧНЫЕ ВЫРАЖЕНИЯ Вас беспокоят (ит) глаза (зрение)? У вас хорошее (плохое) зрение? Вы видите лучше вдали или вблизи? 70 TYPICAL EXPRESSION Do you have any trouble with your eyes (eyesight)? Do you have good (poor) vision? Do you see better at a distance or near to? Каким глазом вы видите хуже? Когда последний раз вы проверяли зрение? Назовите букву, на которую я показываю У вас абсолютно нормальное зрение (дальнозоркость, близорукость, высокая степень близорукости, слабая степень дальнозоркости) У вас косоглазие с детства? Вы видите ясно (нечетко, как в тумане)? Вы постоянно носите очки? Какие? Вы пользуетесь очками только для работы на близком расстоянии (для дали)? Вы должны носить очки постоянно (по необходимости) Вам нужны очки для чтения (для дали) Which eye do you see worse with? When did you last have your eyes tested? What letter am I pointing to? Your eyesight is quite normal (you are longsighted, nearsighted, you have a high degree of nearsightedness, a slight degree of longsightedness) Have you had a squint since childhood? Is your sight clear (blurred, dim)? Do you wear glasses permanently? What kind of glasses? Do you use glasses only for shortdistance (long-distance) work? You must wear your glasses permanently (only when necessary) You need glasses for reading (for distant vision) I'll prescribe glasses for shortЯ вам выпишу рецепт на очки для distance work (for long-distance работы вблизи (для дали, для work, for permanent wear) постоянного пользования) Do you see double? У вас есть двоение в глазах? Can you see better at dusk or in Вы лучше видите в сумерки или bright light? при ярком свете? Can you distinguish all colours? Вы различаете все цвета? Are your eyes often red and У вас часто краснеют и восinflamed? (Do your eyes form pus паляются глаза (нагнаиваются sometimes? Do you often have иногда глаза, часто бывают sties?) ячмени)? Do your eyelids stick together in the Края век утром слипаются? morning? Do you often have severe pains in Вы часто ощущаете сильную боль the eyes? 71 в глазах? Бывает ли у вас слизисто-гнойное отделяемое в уголках глаз? У вас есть ощущение засоренности глаз песком (ощущение инородного тела за веками, постоянный мучительный зуд в веках, постоянное раздражение век, выраженная чувствительность к пыли, искусственному свету)? Вас беспокоит постоянное слезотечение (спазм век)? В вашей семье есть больные Do you have a discharge of mucus and pus at the corners of the eyes? Do you have a gritty feeling in the eyes (a sensation of a foreign body present behind the eyelids, persistent troublesome itching in the eyelids, constant irritation of the eyelids, pronounced sensitivity to dust, artificial light)? Are you troubled with persistent eyewatering (eyelid spasm)? Is there a history of glaucoma in your family? Do you have headache (eye pain глаукомой? after sleep)? У вас бывает головная боль (боль Do you have periodical failing в глазах утром после сна)? vision (seeing rainbow effects У вас бывает(ют) периодическое around a distant light, discomfort in ухудшение зрения (видение the eyes after excitement or in радужных кругов вокруг reduced illumination)? источника света, находящегося на расстоянии, неприятные ощущения в глазах после Have you [ever] noticed that one of волнения или при плохом your pupils is larger than the other? освещении)? Вы [когда-нибудь] замечали, что у вас один зрачок шире, чем другой? У больного(ой) стало быстро ухудшаться зрение У больного(ой) что-то с глазами A The patient has developed rapidly failing vision There is something wrong with the patient's eyes Установите офтальмоскоп на О Set the ophthalmoscope at О diopters. Darken the room диоптрий. Затемните комнату Check visual acuity and fields 72 Проверьте остроту зрения и поля зрения Определите степень косоглазия! Выверните веко! Приподнимите слегка веко! Поставьте канальцевую (носовую) пробу Функция канальцев сохранена Слеза свободно проходит в слезный мешок Канальцевая проба положительная, слезноносовая проба отрицательная Определите проходимость слезоотводящих путей Какие зрачки у больного(ой)? Зрачки круглые (правильной формы, равномерно реагируют на Measure the degree of strabismus Evert the lid. Raise the upper eyelid slightly Do a ductus (nasal) test Ductus function is retained The tear passes into the lac-rimal sac easily Test of the duct is positive, lacrimonasal test is negative Determine if the lacrimal passage is patent What is the pupillary status? The pupils are round (regular, react equally to light and accomodation) свет и аккомодацию) Направляйте свет на каждый зрачок по очереди Исследуйте реакцию зрачков Зрачки расширены (сужены, неодинаковых размеров, симметричны) Левый зрачок шире, чем правый Shine a light on each pupil in turn Observe the pupillary response The pupils are dilated (constricted, unequal in size, symmetrical) The left pupil is larger than the right one Pupil size and reaction to light are Размер зрачков и реакция на свет adequate адекватны Test the corneal reflex Проверьте роговичный рефлекс! Touch the cornea with a fine wisp of Коснитесь роговицы тонким cotton жгутиком ваты Не назначайте средств, расDon't order mydriatics without a ширяющих зрачок, без кон- consultation with an ophthalmologist 73 сультации с офтальмологом! Больной(ая) жалуется на затуманивание зрения (видение радужных кругов перед глазами, одностороннюю головную боль) Проведите тонометрию (компрессионно-тонометрическую пробу, гониоскопию) У больного(ой) язва роговицы (бельмо роговицы, разрыв радужки) Тушируйте язву роговицы Сделайте криоаппликацию (фотокоагуляцию, лазерокоагуляцию, кератопластику) Отмечается перикорнеальная инъекция глаза (углубление передней камеры глаза, помутнение ее влаги, изменение цвета и рисунка радужной оболочки) Роговица блестящая (прозрачная, тусклая, мутная) Выделения из глаз гнойные (обильные, сливкообразной консистенции, желтого цвета) Конъюнктива нормальной окраски (отечная, гипертрофирована, разрыхлена, инфильтрирована, набухшая, яркокрасного цвета) Отмечается болезненность глазного яблока (светобоязнь, покраснение век) Диск зрительного нерва отечен (гиперемирован, розовато-серый, 74 The patient complains of clouding of vision (rainbow vision, one-sided headache) Perform tonometry (compressiontonometric test, gonioscopy) The patient has a corneal ulcer (a corneal spot, rupture of iris) Paint the corneal ulcer Perform cryoapplication (photocoagulation, laser coagulation, keratoplasty) There is pericorneal injection of the eye (recess of the anterior ocular chamber, clouding of its humor, change in colour and pattern of the iris) The cornea is bright (trans-parant, dull, opaque) Eye discharges are purulent (profuse, of cream-like consistency, of yellow colour) Conjunctiva is of normal colour (edematous, hypertro-phic, loose, infiltrated, swollen, of bright-red colour) There is eyeball tenderness (photofobia, reddening of the eyelids) The optic disk is edematous (reddened, pinkish-gray, dis- обесцвечен) coloured) Границы диска зрительного нерва четкие (нечеткие) Отмечается выраженное (незначительное) кровоизлияние в сетчатку, частичное (краевое, тотальное) отслоение сетчатки Показана диатермокоагуляция (криопексия) Сосуды сетчатки резко расширены (сужены, извиты, прерываются) Закапайте в глаз пипеткой дезинфицирующий раствор (раствор пилокарпина, раствор альбуцида) Заложите в конъюнктивальный мешок дезинфицирующую мазь The optic disk borders are distinct (blurred) There is pronounced (slight) bleeding into the retina, partial (marginal, total) detachment of the retina There is indicated diathermocoagulation (cryopexy) Промойте конъюнктивальный мешок (слезные пути) дезинфицирующим раствором Wash out the conjunctival sac (lacrimal ducts) with a disinfectant solution Retinal vessels are greatly dilated (narrowed, tortuous, interrupt) Put with an eye dropper a disinfectant solution (a pilo-carpine solution, an albucid solution) into the eye Place some disinfectant salve into the conjunctival sac Conclusion Independent work of a student with a patient on the ophthalmology department is very important. To examine a patient, students must know special methods of ophthalmologic examination. Various ophthalmologic pathology demands different methods of examination to be applied depending on the character of the disease. The basic goal of given methodical recommendations is to help students in acquiring the skills to work independently. 75 Literature 1. А.А. Бочкарева Глазные болезни, М.: Медицина, 1989 – 414 с. 2. Т.И. Ерошевский, А.А. Бочкарева Глазные болезни, М.: Медицина, 1983 –448 с. 3. Lang G.K., Ophthalmology, Stuttgart, New York, 2000 – p. 1-16. 4. James B., Chew C., Bron A., Lecture Notes on Ophthalmology, 2000 – p.19-35. 5. Practical skills in Ophthalmology, Ryazan, 2004 – 95 p. 76
