Retinal examination. Computer vision diagnostics. Ophthalmologist services are paid or free

Vision diagnostics- this is an important step in the prevention of eye diseases and maintaining good vision for many years! Timely detection of ophthalmological pathology is the key to successful treatment of many eye diseases. As our practice shows, the occurrence of eye diseases is possible at any age, so everyone needs to undergo a high-quality ophthalmological examination at least once a year.

Why is a complete vision diagnostic necessary?

Vision diagnostics is necessary not only to identify primary ophthalmological pathology, but also to resolve the issue of the possibility and advisability of performing a particular operation, choosing patient treatment tactics, as well as accurately diagnosing the condition of the organ of vision in a dynamic aspect. In our clinic, a complete ophthalmological examination is carried out using the most modern diagnostic equipment.

Cost of vision diagnostics

The cost of a diagnostic examination (vision diagnostics) depends on its volume. For the convenience of patients, we have created complexes in accordance with common eye diseases, such as cataracts, glaucoma, myopia, farsightedness, and fundus pathology.

What tests are included in a complete diagnostic examination of the visual system and what are they?

Any ophthalmological examination begins, first of all, with a conversation, identifying the patient’s complaints and collecting an anamnesis. And only after this they move on to hardware methods for studying the organ of vision. The hardware diagnostic examination includes determining visual acuity, studying the patient’s refraction, measuring intraocular pressure, examining the eye under a microscope (biomicroscopy), pachymetry (measuring the thickness of the cornea), echobiometry (determining the length of the eye), ultrasound examination of the eye (B-scan), computer keratotopography and careful (of the fundus) with a wide pupil, determining the level of tear production, assessing the patient’s field of vision. When ophthalmological pathology is detected, the scope of the examination is expanded to specifically study the clinical manifestations in a particular patient. Our clinic is equipped with modern, highly professional ophthalmological equipment from companies such as ALCON, Bausch & Lomb, NIDEK, Zeiss, Rodenstock, Oculus, which allows us to conduct studies of any level of complexity.

In our clinic, special tables with pictures, letters or other signs are used to determine the patient’s visual acuity and refraction. Using an automatic phoropter NIDEK RT-2100 (Japan), the doctor, alternately changing the diopter glasses, selects the most optimal lenses that provide the best vision for the patient. In our clinic, we use NIDEK SCP - 670 halogen sign projectors with 26 test patterns and analyze the results obtained under narrow and wide pupil conditions. Computer refraction research is carried out on a NIDEK ARK-710A autorefractive meter (Japan), which allows you to most accurately determine the refraction of the eye and the biometric parameters of the cornea.

Intraocular pressure is measured using a non-contact tonometer NIDEK NT-2000. If necessary, measurement of intraocular pressure is carried out by contact method - Maklakov or Goldman tonometers.

To examine the condition of the anterior segment of the eye (eyelids, eyelashes, conjunctiva, cornea, iris, lens, etc.), a NIDEK SL-1800 slit lamp (biomicroscope) is used. On it, the doctor evaluates the condition of the cornea, as well as deeper structures such as the lens and vitreous body.

All patients undergoing a complete ophthalmological examination are required to undergo an examination of the fundus, including areas of its extreme periphery, under conditions of maximum pupil dilation. This makes it possible to identify dystrophic changes in the retina, diagnose its breaks and subclinical detachments - a pathology that is not clinically determined by the patient, but requires mandatory treatment. To dilate the pupils (mydriasis), fast and short-acting drugs are used (Midrum, Midriacil, Cyclomed). If changes are detected in the retina, we prescribe preventive laser coagulation using a special laser. Our clinic uses the best and most modern models: YAG laser, NIDEK DC-3000 diode laser.

One of the important methods for diagnosing a patient’s vision before any refractive surgery for vision correction is computer topography of the cornea, aimed at examining the surface of the cornea and its pachymetry - measuring its thickness.

One of the anatomical manifestations of refractive error (myopia,) is a change in the length of the eye. This is one of the most important indicators, which in our clinic is determined using a non-contact method using the IOL MASTER device from ZEISS (Germany). This is a combined biometric device, the research results of which are also important for calculating IOLs for cataracts. Using this device, during one session, the length of the eye axis, the radius of curvature of the cornea and the depth of the anterior chamber of the eye are measured immediately one after another. All measurements are carried out using a non-contact method, which is extremely comfortable for the patient. Based on the measured values, the built-in computer can suggest optimal intraocular lenses. The basis for this is the current international calculation formulas.

Ultrasound examination is an important addition to generally accepted clinical methods of ophthalmological diagnostics; it is a widely known and informative instrumental method. This study makes it possible to obtain information about the topography and structure of normal and pathological changes in the tissues of the eye and orbit. Using the A-method (one-dimensional imaging system), the thickness of the cornea, the depth of the anterior chamber, the thickness of the lens and inner membranes of the eye, as well as the length of the eye are measured. The B-method (two-dimensional imaging system) allows you to assess the condition of the vitreous body, diagnose and evaluate the height and extent of choroidal and retinal detachment, identify and determine the size and localization of ocular and retrobulbar neoplasms, as well as detect and determine the location of a foreign body in the eye.

Visual field examination

Another necessary method for diagnosing vision is visual field testing. The purpose of determining the field of view (perimetry) is:

• diagnosis of eye diseases, in particular glaucoma
• dynamic observation to prevent the development of eye diseases.

Also, using hardware techniques, it is possible to measure the contrast and threshold sensitivity of the retina. These studies provide the possibility of early diagnosis and treatment of a number of eye diseases.

In addition, other parametric and functional data of the patient are examined, for example, determining the level of tear production. The most diagnostically sensitive functional studies are used - the Schirmer test, the Norn test.

Optical tomography of the retina

Another modern method for studying the inner lining of the eye is. This unique technique allows you to get an idea of ​​the structure of the retina throughout its entire depth, and even measure the thickness of its individual layers. With its help, it became possible to detect the earliest and smallest changes in the structure of the retina and optic nerve, which are not accessible to the resolving abilities of the human eye.

The operating principle of an optical tomograph is based on the phenomenon of light interference, which means that the patient is not exposed to any harmful radiation during the study. The examination takes a few minutes, does not cause visual fatigue and does not require direct contact of the device’s sensor with the eye. Similar devices for vision diagnostics are available only in large clinics in Russia, Western Europe and the USA. The study provides valuable diagnostic information about the structure of the retina in diabetic macular edema and allows you to accurately formulate a diagnosis in complex cases, as well as obtain a unique opportunity to monitor the dynamics of treatment based not on the subjective impression of the doctor, but on clearly defined digital values ​​of retinal thickness.

The study provides comprehensive information about the condition of the optic nerve and the thickness of the layer of nerve fibers around it. High-precision measurement of the latter parameter guarantees the identification of the earliest signs of this terrible disease, even before the patient notices the first symptoms. Considering the ease of implementation and the absence of unpleasant sensations during the examination, we recommend repeating control examinations on the scanner for glaucoma every 2-3 months, for diseases of the central zone of the retina - every 5-6 months.

Repeated examination allows you to determine the activity of the pathology, clarify the correctness of the chosen treatment, and also correctly inform the patient about the prognosis of the disease, which is especially important for patients suffering from macular holes, since the likelihood of a similar process developing in a healthy eye can be predicted after a tomograph study. Early, “preclinical” diagnosis of fundus changes in diabetes mellitus is also possible with this amazing device.

What happens after hardware research is completed?

After completing hardware tests (vision diagnostics), the doctor carefully analyzes and interprets all the information received about the condition of the patient’s organ of vision and, based on the data obtained, makes a diagnosis, on the basis of which a treatment plan for the patient is drawn up. All research results and treatment plan are explained to the patient in detail.

Modern people are hostages of a hectic life in huge cities, with virtually no time left to take care of their own health. Therefore, visits to the doctor, especially preventive ones, are very rare, but it is easier to prevent or treat diseases at an early stage than to bravely fight the consequences of an advanced disease.

This truth is 100% true in relation to eye diseases, which have recently become “younger”, like other diseases of the body. Taking care of the health of the visual system of our patients, and taking into account the total lack of free time, Dr. Shilova’s Clinic has introduced an effective method for comprehensive diagnostics of the visual organ in one visit to an ophthalmologist.

This technique is universal, but at the same time, it is individual and allows you to fully take into account the characteristics of the eyes of each individual person. After the initial appointment, analysis of symptoms and study of possible available medical documentation, an experienced specialist determines a set of necessary diagnostic procedures that will create a complete picture of the health of the visual system on the same day.

Equipment for computer diagnostics is a source of special pride for our clinic. It is considered one of the most high-precision not only in Moscow, but also in the world. Advanced diagnostic technology, the use of innovative research methods and the experience of ophthalmologists working in the clinic guarantee the success of a complete examination of the visual system.

Video about types of vision examinations

Our eye clinic in the television program “Diagnostic Method”.

At the Clinic of Dr. Shilova, the patient is offered:

• Checking visual acuity using traditional (subjective) and computer methods, with and without correction (when only a consultation is needed).
• Selection of contact lenses and glasses of any complexity.
• Autorefkeratometry – determination of the clinical refraction of the eye (detection of myopia, farsightedness, astigmatism).
• Pneumotonometry is a non-contact, computerized study of IOP using an air jet, which is indispensable in the early diagnosis of glaucoma.
• Echobiometry is a non-contact measurement of the parameters of the human eye (its length, thickness of the lens, pupil diameter, depth of the anterior chamber, etc.), using a unique ultrasound device AL-Scan (NIDEK, Japan). This study is mandatory when calculating the power of an intraocular lens in cataract surgery, to identify the progression of the myopic process, etc.
• Biomicroscopic examination is an examination of the fundus using a fundus lens, revealing pathologies in the central as well as peripheral areas of the retina and optic nerve. It is necessary for patients with any degree of myopia and retinal dystrophy.
• Perimetry is a study of the visual fields for each eye using a special computer perimeter. The study is mandatory in diagnosing the degree of glaucoma, damage to the optic nerve, and diseases of the central nervous system.
• Echoscopy using the A-method is an ultrasound examination of the intraocular membranes and media to detect retinal detachment, tumors and hemorrhages in the eye.
• Echoscopy using the B-method is an ultrasound of the eyeball to determine existing pathologies in the case of opaque optical media, which is prescribed as an addition to a full diagnostic examination of the eyes.
• Keratopachymetry is an ultrasound examination of the thickness of the cornea, important in the diagnosis of keratoconus, as well as during laser vision correction.
• Computer keratotopography is a study of the curvature of the corneal surface, which is mandatory to clarify the degree of astigmatism and diagnose keratoconus, and is also necessary when performing laser vision correction.

Specialists at Dr. Shilova’s Clinic strongly recommend that every patient undergo a set of diagnostic procedures if:

• The last visit to the ophthalmologist was a year or more ago.
• Work involves overexertion or eye strain.
• Parents or close relatives have been diagnosed with eye diseases.

Do not put off an ophthalmological examination “for later”. Be sure to make an appointment with your doctor at a time that is convenient for you. Come see us after work or on a weekend with the whole family and turn your routine inspection into a fun adventure. Needless to say, good vision costs much more than the 60 minutes spent on the examination!

Surprisingly, a huge arsenal of examinations and diagnostic procedures is aimed at such a small organ of vision: from simple alphabetic tables to obtaining a layer-by-layer image of the retina and optic nerve head using OCT and a detailed study of the course of blood vessels in the fundus during FA.

Most studies are carried out according to strict indications. However, when going to see an ophthalmologist, be prepared to spend from half an hour to an hour or more, depending on the number and complexity of the tests you need and the workload of your doctor.

Determination of visual acuity and refraction

Visual acuity is determined for each eye separately. In this case, one of them is covered with a shield or palm. At a distance of 5 meters you will be shown letters, numbers or signs of various sizes that you will be asked to name. Visual acuity is characterized by the smallest signs that the eye can distinguish.

Next, you will be given a frame in which the doctor will put different lenses, asking you to choose which one allows you to see more clearly. Or they will install in front of you a device called a phoropter, in which lenses are changed automatically. Refraction is characterized by the power of the lens, which provides the highest visual acuity for that eye, and is expressed in diopters. Positive lenses are required for farsightedness, negative lenses for myopia, and cylindrical lenses for astigmatism.

Automatic refractometry and aberrometry

An aberrometer, based on an analysis of the wavefront of the eye, determines even imperceptible optical imperfections of its media. These data are important when planning LASIK.

Visual field examination

It is carried out using a device - a perimeter, which is a hemispherical screen. You are asked to fixate the mark with your eye and, as soon as you notice with your peripheral vision the luminous dots appearing in different parts of the screen, press the signal button or say “yes”, “I see”. The visual field is characterized by the space in which the eye, with a constantly fixed gaze, detects visual stimuli. Characteristic visual field defects occur due to eye diseases, such as glaucoma, as well as when the optic nerve and brain are damaged by a tumor or as a result of a stroke.

Measuring intraocular pressure

Non-contact measurement is carried out using an automatic tonometer. You are asked to place your chin on the stand of the device and fixate your gaze on the luminous mark. The autotonometer releases a stream of air in the direction of your eye. Based on the cornea's resistance to air flow, the device determines the level of intraocular pressure. The technique is absolutely painless, the device does not come into contact with your eyes.

The contact method for measuring intraocular pressure has been accepted as standard in Russia. After instilling the “freezing” drops, the doctor touches your cornea with a weight with a colored area. The level of intraocular pressure is determined on paper by the diameter of the imprint of the unpainted area. This technique is also painless.

Since glaucoma is a disease associated with increased intraocular pressure, regular measurement of it is a necessary condition for maintaining the health of your eyes.

Cover test

There are many methods for diagnosing strabismus. The simplest of them is the “cover” test. The doctor asks you to fix your gaze on an object in the distance and, alternately covering one of your eyes with your palm, watches the other to see if there is an orientation movement. If it occurs inwardly, divergent strabismus is diagnosed, if outwardly, convergent strabismus is diagnosed.

Biomicroscopy of the eye

A slit lamp or biomicroscope allows you to examine the structures of the eye under high magnification. You are asked to place your chin on the stand of the device. The doctor illuminates your eye with the light of a slit lamp and, under high magnification, first examines the anterior part of the eye (eyelids, conjunctiva, cornea, iris, lens), and then, using a strong lens, examines the fundus of the eye (retina, optic nerve head and blood vessels). Biomicroscopy allows you to diagnose almost the entire range of eye diseases.

Retinal examination

Using an ophthalmoscope, the doctor directs a beam of light into your eye and examines the retina, optic nerve head and blood vessels through the pupil.

Often, for a more complete view, you are first instilled with drops that dilate the pupil. The effect develops after 15-30 minutes. While they last, sometimes for several hours, you may experience difficulty focusing on nearby objects. In addition, the eye's sensitivity to light increases; it is recommended to wear sunglasses on the way home after the examination.

■ Patient complaints

■ Clinical examination

External examination and palpation

Ophthalmoscopy

■ Instrumental examination methods

Biomicroscopy Gonioscopy

Echoophthalmography

Entoptometry

Fluorescein angiography of the retina

■ Examination of the organ of vision in children

PATIENT'S COMPLAINTS

With diseases of the organ of vision, patients complain of:

Decreased or changed vision;

Pain or discomfort in the eyeball and surrounding areas;

lacrimation;

External changes in the condition of the eyeball itself or its appendages.

Visual impairment

Decreased visual acuity

It is necessary to find out what visual acuity the patient had before the illness; whether the patient discovered decreased vision by chance or can he accurately indicate under what circumstances this occurred; sn-

whether vision decreased gradually or whether its deterioration occurred quite quickly in one or both eyes.

Three groups of reasons can be distinguished that lead to a decrease in visual acuity: refractive errors, clouding of the optical media of the eyeball (cornea, anterior chamber moisture, lens and vitreous body), as well as diseases of the neurosensory apparatus (retina, pathways and cortical part of the visual analyzer).

Vision changes

Metamorphopsia, macropsia And micropsies concern patients in case of localization of pathological processes in the macular area. Metamorphopsia is characterized by distortion of the shapes and outlines of objects, curvature of straight lines. With micro- and macropsia, the observed object appears to be either smaller or larger in size than it actually exists.

Diplopia(double vision) can only occur when fixating an object with both eyes, and is caused by a violation of the synchronization of eye movements and the inability to project an image onto the central fovea of ​​both eyes, as occurs normally. When one eye is closed, diplopia disappears. Causes: disruption of the innervation of the external muscles of the eye or uneven displacement of the eyeball due to the presence of a space-occupying formation in the orbit.

Hemeralopia accompanies diseases such as hypovitaminosis A, retinitis pigmentosa, siderosis and some others.

Photophobia(photophobia) indicates inflammatory diseases or injury to the anterior segment of the eye. In this case, the patient tries to turn away from the light source or close the affected eye.

Glare(glare) - severe visual discomfort when bright light enters the eyes. It is observed with some cataracts, aphakia, albinism, cicatricial changes in the cornea, especially after radial keratotomy.

Seeing halos or rainbow circles around the light source occurs due to swelling of the cornea (for example, during a microattack of angle-closure glaucoma).

Photopsias- seeing flashes and lightning in the eye. Causes: vitreoretinal traction with incipient retinal detachment or short-term spasms of retinal vessels. Also photo

psia occur when the primary cortical centers of vision are affected (for example, by tumor).

The appearance of "flying flies" caused by the projection of the shadow of vitreous opacities onto the retina. They are perceived by the patient as points or lines that move along with the movement of the eyeball and continue to move after it stops. These “floaters” are especially characteristic of the destruction of the vitreous body in the elderly and patients with myopia.

Pain and discomfort

Unpleasant sensations in diseases of the organ of vision can be of a different nature (from a burning sensation to severe pain) and localized in the eyelid area, in the eyeball itself, around the eye in the orbit, and also manifest itself as a headache.

Pain in the eye indicates inflammatory processes in the anterior segment of the eyeball.

Unpleasant sensations in the eyelid area are observed in diseases such as stye and blepharitis.

Pain around the eye in the orbit occurs with lesions of the conjunctiva, injuries and inflammatory processes in the orbit.

Headache on the side of the affected eye is observed during an acute attack of glaucoma.

Asthenopia- unpleasant sensations in the eyeballs and orbits, accompanied by pain in the forehead, eyebrows, back of the head, and sometimes even nausea and vomiting. This condition develops as a result of prolonged work with objects located near the eye, especially in the presence of ametropia.

Tearing

Lacrimation occurs in cases of mechanical or chemical irritation of the conjunctiva, as well as with increased sensitivity of the anterior segment of the eye. Persistent lacrimation may result from increased tear production, impaired tear evacuation, or a combination of both mechanisms. Strengthening the secretory function of the lacrimal gland is reflexive in nature and occurs when the facial, trigeminal or cervical sympathetic nerve is irritated (for example, with conjunctivitis, blepharitis, and some hormonal diseases). A more common cause of lacrimation is impaired evacuation.

ation of tears along the lacrimal ducts due to pathology of the lacrimal openings, lacrimal canaliculi, lacrimal sac and nasolacrimal duct.

CLINICAL EXAMINATION

The examination always begins with the healthy eye, and in the absence of complaints (for example, during a preventive examination) - with the right eye. An examination of the organ of vision, regardless of the patient’s complaints and the doctor’s first impression, must be carried out consistently, according to the anatomical principle. An eye examination begins after a vision test, since after diagnostic tests it may worsen for a while.

External examination and palpation

The purpose of the external examination is to assess the condition of the orbital margin, eyelids, lacrimal organs and conjunctiva, as well as the position of the eyeball in the orbit and its mobility. The patient is seated facing the light source. The doctor sits opposite the patient.

First, the areas of the eyebrows, the bridge of the nose, the upper jaw, the zygomatic and temporal bones, and the area where the preauricular lymph nodes are located are examined. The condition of these lymph nodes and the edges of the orbit is assessed by palpation. Sensitivity is checked at the exit points of the branches of the trigeminal nerve, for which a point located on the border of the inner and middle third of the upper edge of the orbit is simultaneously palpated on both sides, and then a point located 4 mm below the middle of the lower edge of the orbit.

Eyelids

When examining the eyelids, you should pay attention to their position, mobility, condition of the skin, eyelashes, anterior and posterior ribs, intercostal space, lacrimal openings and excretory ducts of the meibomian glands.

Skin of the eyelidsNormally, it is thin, tender, with loose subcutaneous tissue located underneath it, as a result of which swelling easily develops in the eyelid area:

In case of general diseases (kidney and cardiovascular diseases) and allergic angioedema, the process is bilateral, the skin of the eyelids is pale;

In inflammatory processes of the eyelid or conjunctiva, the swelling is usually one-sided, the skin of the eyelids is hyperemic.

The edges of the eyelids. Hyperemia of the ciliary edge of the eyelids is observed during the inflammatory process (blepharitis). Also, the edges may be covered with scales or crusts, after removal of which bleeding ulcers are found. Reduction or even baldness (madarosis) of the eyelid, abnormal growth of eyelashes (trichiasis) indicate a chronic inflammatory process or a previous disease of the eyelids and conjunctiva.

Palpebral fissure. Normally, the length of the palpebral fissure is 30-35 mm, width 8-15 mm, the upper eyelid covers the cornea by 1-2 mm, the edge of the lower eyelid does not reach the limbus by 0.5-1 mm. Due to disturbances in the structure or position of the eyelids, the following pathological conditions arise:

Lagophthalmos, or “hare's eye”, is non-closure of the eyelids and gaping of the palpebral fissure with paralysis of the orbicularis oculi muscle (for example, with damage to the facial nerve);

Ptosis is a drooping of the upper eyelid that occurs when the oculomotor or cervical sympathetic nerve is damaged (as part of Bernard-Horner syndrome);

A wide palpebral fissure is characteristic of irritation of the cervical sympathetic nerve and Graves' disease;

Narrowing of the palpebral fissure (spastic blepharospasm) occurs due to inflammation of the conjunctiva and cornea;

Entropion is an inversion of the eyelid, usually the lower one, which can be senile, paralytic, cicatricial and spastic;

Ectropion - inversion of the eyelid, can be senile, cicatricial and spastic;

Coloboma of the eyelids is a congenital defect of the eyelids in the form of a triangle.

Conjunctiva

When the palpebral fissure is open, only part of the conjunctiva of the eyeball is visible. The conjunctiva of the lower eyelid, the lower transitional fold and the lower half of the eyeball is examined with the edge of the eyelid pulled down and the patient's gaze fixed upward. To examine the conjunctiva of the upper transitional fold and the upper eyelid, it is necessary to evert the latter. To do this, ask the subject to look down. The doctor, with the thumb and forefinger of his right hand, fixes the eyelid by the edge and pulls it down and forward, and then

with the index finger of the left hand, moves the upper edge of the cartilage down (Fig. 4.1).

Rice. 4.1.Stages of upper eyelid eversion

Normally, the conjunctiva of the eyelids and transitional folds is pale pink, smooth, shiny, with vessels visible through it. The conjunctiva of the eyeball is transparent. There should be no discharge in the conjunctival cavity.

Redness (injection) eyeball develops with inflammatory diseases of the organ of vision due to dilation of the vessels of the conjunctiva and sclera. There are three types of injection of the eyeball (Table 4.1, Fig. 4.2): superficial (conjunctival), deep (pericorneal) and mixed.

Table 4.1.Distinctive features of superficial and deep injection of the eyeball

Rice. 4.2.Types of injections of the eyeball and types of vascularization of the cornea: 1 - superficial (conjunctival) injection; 2 - deep (pericorneal) injection; 3 - mixed injection; 4 - superficial vascularization of the cornea; 5 - deep vascularization of the cornea; 6 - mixed vascularization of the cornea

Chemosis of the conjunctiva - pinching of the conjunctiva within the palpebral fissure due to severe swelling.

Eyeball position

When analyzing the position of the eye in the orbit, attention is paid to the protrusion, retraction or displacement of the eyeball. In some cases, the position of the eyeball is determined using a Hertel mirror exophthalmometer. The following options for the position of the eyeball in the orbit are distinguished: normal, exophthalmos (anterior protrusion of the eyeball), enophthalmos (retraction of the eyeball), lateral displacement of the eye and anophthalmos (absence of the eyeball in the orbit).

Exophthalmos(proportion of the eye anteriorly) is observed in thyrotoxicosis, trauma, orbital tumors. To differentiate these conditions, reposition of the protruding eye is performed. For this purpose, the doctor presses the patient’s eyeballs through the eyelids with his thumbs and assesses the degree of their displacement inside the orbit. With exophthalmos caused by a neoplasm, difficulty in repositioning the eyeball into the orbital cavity is determined.

Enophthalmos(retraction of the eyeball) occurs after fractures of the orbital bones, with damage to the cervical sympathetic nerve (as part of Bernard-Horner syndrome), as well as with atrophy of retrobulbar tissue.

Lateral displacement of the eyeball can be due to a space-occupying formation in the orbit, an imbalance in the tone of the extraocular muscles, a violation of the integrity of the orbital walls, or inflammation of the lacrimal gland.

Motility disorders of the eyeball are more often the result of diseases of the central nervous system and paranasal sinuses

nose When examining the range of motion of the eyeballs, the patient is asked to follow the movement of the doctor’s finger to the right, left, up and down. They observe how far the eyeball reaches during the study, as well as the symmetry of eye movements. The movement of the eyeball is always limited towards the affected muscle.

Lacrimal organs

The lacrimal gland is normally inaccessible to our examination. It protrudes from under the upper edge of the orbit during pathological processes (Mikulich syndrome, tumors of the lacrimal gland). The accessory lacrimal glands located in the conjunctiva are also not visible.

When examining the lacrimal openings, pay attention to their size, position, and their contact with the conjunctiva of the eyeball when blinking. When you press on the area of ​​the lacrimal sac, there should be no discharge from the lacrimal openings. The appearance of tears indicates a violation of the outflow of tear fluid through the nasolacrimal duct, and mucus or pus indicates inflammation of the lacrimal sac.

Tear production is assessed using the Schirmer test: a strip of filter paper 35 mm long and 5 mm wide with one pre-curved end is inserted behind the lower eyelid of the subject (Fig. 4.3). The test is carried out with eyes closed. After 5 minutes, the strip is removed. Normally, a section of the strip more than 15 mm long is wetted with tears.

Rice. 4.3. Schirmer test

Functional patency lacrimal ducts evaluate several methods.

Tubular test. Instilled into the conjunctival sac

3% collargol solution? or 1% sodium fluorescein solution.

Normally, due to the suction function of the eye tubules,

The apple becomes discolored within 1-2 minutes (positive tubular test).

Nasal test. Before instilling the dyes into the conjunctival sac, a probe with a cotton swab is inserted under the inferior turbinate. Normally, after 3-5 minutes, the cotton swab is stained with dye (positive nasal test).

Washing the lacrimal ducts. The lacrimal punctum is expanded with a conical probe and the patient is asked to tilt his head forward. A cannula is inserted into the lacrimal canaliculus 5-6 mm and a sterile 0.9% sodium chloride solution is slowly poured in using a syringe. Normally, fluid flows out of the nose in a trickle.

Side (focal) lighting method

This method is used to study the conjunctiva of the eyelids and eyeball, sclera, cornea, anterior chamber, iris and pupil (Fig. 4.4).

The study is carried out in a darkened room. The table lamp is installed at eye level of the seated patient, at a distance of 40-50 cm, to the left and slightly in front of him. The doctor takes a +20 diopter magnifying glass in his right hand and holds it at a distance of 5-6 cm from the patient’s eye, perpendicular to the rays coming from the light source, and focuses the light on the area of ​​the eye that is to be examined. Thanks to the contrast between a brightly lit small area of ​​the eye and the unlit neighboring parts of it, changes are better visible. When examining the left eye, the doctor fixes his right hand, resting his little finger on the cheekbone; when examining the right eye, on the back of the nose or forehead.

The sclera is clearly visible through the transparent conjunctiva and is normally white. A yellow coloration of the sclera is observed in jaundice. Staphylomas may be observed - dark brown areas of protrusion of sharply thinned sclera.

Cornea. Ingrowth of blood vessels into the cornea occurs under pathological conditions. Minor defects

Rice. 4.4.Side (focal) lighting method

You of the corneal epithelium are detected by staining with 1% sodium fluorescein solution. The cornea may have opacities of varying location, size, shape and intensity. The sensitivity of the cornea is determined by touching the center of the cornea with a cotton wick. Normally, the patient notices the touch and tries to close the eye (corneal reflex). When sensitivity decreases, the reflex is caused only by placing a thicker part of the wick. If the corneal reflex could not be evoked in the patient, then there is no sensitivity.

Anterior chamber of the eye. The depth of the anterior chamber is assessed when viewed from the side by the distance between the light reflexes appearing on the cornea and iris (normally 3-3.5 mm). Normally, the moisture in the anterior chamber is completely transparent. In pathological processes, an admixture of blood (hyphema) or exudate may be observed in it.

Iris. Eye color is usually the same on both sides. A change in the color of the iris of one eye is called anisochromia. It is more often congenital, less often - acquired (for example, with inflammation of the iris). Sometimes iris defects are found - colobomas, which can be peripheral or complete. Severing the iris from the root is called iridodialysis. With aphakia and lens subluxation, iris trembling (iridodonesis) is observed.

The pupil is visible as a black circle in side lighting. Normally, the pupils are the same in size (2.5-4 mm in moderate lighting). Constriction of the pupil is called miosis, extension - mydriasis, different pupil sizes - anisocoria.

The reaction of the pupils to light is tested in a dark room. The pupil is illuminated with a flashlight. When one eye is illuminated, its pupil constricts (direct pupil reaction to light), as well as the pupil of the other eye constricts (cooperative pupil reaction to light). The pupillary reaction is considered “alive” if, under the influence of light, the pupil quickly narrows, and “sluggish” if the pupil reaction is slow and insufficient. The pupil may not react to light.

The reaction of the pupils to accommodation and convergence is checked when moving the gaze from a distant object to a close object. Normally, the pupils constrict.

The lens is not visible in lateral lighting, except in cases of clouding (total or anterior).

Transmitted light examination

This method is used to assess the transparency of the optical media of the eye - the cornea, anterior chamber moisture, lens and vitreous body. Since the transparency of the cornea and the moisture of the anterior chamber can be assessed with lateral illumination of the eye, a study with transmitted light is aimed at analyzing the transparency of the lens and vitreous body.

The study is carried out in a darkened room. The lighting lamp is placed to the left and behind the patient. The doctor holds an ophthalmoscopic mirror in front of his right eye and, directing a beam of light into the pupil of the eye being examined, examines the pupil through the opening of the ophthalmoscope.

The rays reflected from the fundus (mainly from the choroid) are pink. With transparent refractive media of the eye, the doctor sees a uniform pink glow of the pupil (pink reflex from the fundus). Various obstacles in the path of the light beam (that is, clouding of the eye media) delay some of the rays, and dark spots of different shapes and sizes appear against the background of the pink glow. If, when examining the eye in lateral illumination, opacities in the cornea and anterior chamber aqueous are not detected, then the opacities visible in transmitted light are localized either in the lens or in the vitreous body.

Ophthalmoscopy

The method allows you to assess the condition of the fundus (retina, optic nerve head and choroid). Depending on the technique, ophthalmoscopy is distinguished in reverse and direct form. This study is easier and more effective to carry out with a wide pupil.

Reverse ophthalmoscopy

The study is carried out in a darkened room using a mirror ophthalmoscope (a concave mirror with a hole in the center). The light source is placed to the left and behind the patient. With ophthalmoscopy, a uniform glow of the pupil is first obtained, as in a transmitted light study, and then a +13.0 diopter lens is placed in front of the eye being examined. The lens is held with the thumb and index finger of the left hand, resting on the patient's forehead with the middle finger or little finger. Then the lens is moved away from the eye being examined by 7-8 cm, gradually achieving image magnification

pupil so that it occupies the entire surface of the lens. The image of the fundus during reverse ophthalmoscopy is real, enlarged and inverted: the top is visible from below, the right part is visible from the left (that is, the opposite, which explains the name of the method) (Fig. 4.5).

Rice. 4.5.Indirect ophthalmoscopy: a) using a mirror ophthalmoscope; b) using an electric ophthalmoscope

An examination of the fundus is carried out in a certain sequence: they start with the optic nerve head, then examine the macular region, and then the peripheral parts of the retina. When examining the optic disc of the right eye, the patient should look slightly past the doctor’s right ear; when examining the left eye, at the doctor’s left earlobe. The macular area is visible when the patient looks directly into the ophthalmoscope.

The optic disc is round or slightly oval in shape with clear boundaries, yellowish-pink in color. In the center of the disc there is a depression (physiological excavation), caused by bending of the optic nerve fibers.

Fundus vessels. Through the center of the optic disc, the central retinal artery enters and the central retinal vein exits. Once the main trunk of the central retinal artery reaches the surface of the disc, it divides into two branches - superior and inferior, each of which branches into the temporal and nasal. The veins follow the course of the arteries; the ratio of the caliber of arteries and veins in the corresponding trunks is 2:3.

The macula looks like a horizontal oval, slightly darker than the rest of the retina. In young people, this area is bordered by a strip of light - the macular reflex. The central fovea of ​​the macula, which has an even darker color, corresponds to the foveal reflex.

Direct ophthalmoscopy used for detailed examination of the fundus using a hand-held electric ophthalmoscope. Direct ophthalmoscopy allows you to examine small changes in limited areas of the fundus at high magnification (14-16 times, while with reverse ophthalmoscopy the magnification is only 4-5 times).

Ophthalmochromoscopy allows you to examine the fundus of the eye using a special electroophthalmoscope in purple, blue, yellow, green and orange light. This technique allows you to see early changes in the fundus.

A qualitatively new stage in the analysis of the condition of the fundus is the use of laser radiation and computer image assessment.

Measuring intraocular pressure

Intraocular pressure can be determined using indicative (palpation) and instrumental (tonometric) methods.

Palpation method

During the examination, the patient's gaze should be directed downward, eyes closed. The doctor fixes the III, IV and V fingers of both hands on the patient’s forehead and temple, and places the index fingers on the upper eyelid of the eye being examined. Then, alternately with each index finger, the doctor performs light pressing movements on the eyeball several times. The higher the intraocular pressure, the denser the eyeball and the less its walls move under the fingers. Normally, the wall of the eye collapses even with light pressure, that is, the pressure is normal (short notation T N). Eye turgor may be increased or decreased.

There are 3 degrees of increase in eye turgor:

The eyeball is crushed under the fingers, but for this the doctor applies more force - intraocular pressure is increased (T+ 1);

The eyeball is moderately dense (T+ 2);

Finger resistance has been dramatically increased. The doctor's tactile sensations are similar to those felt when palpating the frontal area. The eyeball almost does not fall under the finger - intraocular pressure is sharply increased (T+ 3).

There are 3 degrees of reduction in eye turgor:

The eyeball feels softer to the touch than normal - intraocular pressure is reduced (T -1);

The eyeball is soft, but retains its spherical shape (T -2);

During palpation, no resistance to the wall of the eyeball is felt at all (as when pressing on the cheek) - intraocular pressure is sharply reduced. The eye does not have a spherical shape, or its shape is not preserved upon palpation (T -3).

Tonometry

There are contact (applanation using a Maklakov or Goldman tonometer and impression using a Schiotz tonometer) and non-contact tonometry.

In our country, the most common tonometer is Maklakov, which is a hollow metal cylinder 4 cm high and weighing 10 g. The cylinder is held with a grip handle. Both bases of the cylinder are expanded and form platforms onto which a thin layer of special paint is applied. During the examination, the patient lies on his back, his gaze is fixed strictly vertically. A local anesthetic solution is instilled into the conjunctival cavity. The doctor widens the palpebral fissure with one hand, and with the other sets the tonometer vertically on the eye. Under the weight of the load, the cornea flattens, and at the point of contact of the platform with the cornea, the paint is washed away with a tear. As a result, a circle devoid of paint is formed on the tonometer platform. An imprint of the area is made on paper (Fig. 4.6) and the diameter of the unpainted disc is measured using a special ruler, the divisions of which correspond to the level of intraocular pressure.

Normally, the level of tonometric pressure ranges from 16 to 26 mmHg. It is higher than the true intraocular pressure (9-21 mm Hg) due to the additional resistance provided by the sclera.

Topographyallows you to assess the rate of production and outflow of intraocular fluid. Intraocular pressure is measured

Rice. 4.6.Flattening of the cornea with the Maklakov tonometer platform

for 4 minutes while the sensor is on the cornea. In this case, a gradual decrease in pressure occurs, as part of the intraocular fluid is forced out of the eye. Based on tonography data, one can judge the cause of changes in the level of intraocular pressure.

INSTRUMENTAL METHODS OF EXAMINATION

Biomicroscopy

Biomicroscopy- This is intravital microscopy of eye tissue using a slit lamp. The slit lamp consists of an illuminator and a binocular stereomicroscope.

Light passing through the slit diaphragm forms a light slice of the optical structures of the eye, which is viewed through a slit lamp stereomicroscope. By moving the light slit, the doctor examines all structures of the eye with a magnification of up to 40-60 times. Additional observational, photo- and tele-recording systems, and laser emitters can be introduced into the stereomicroscope.

Gonioscopy

Gopioscopy- a method of studying the angle of the anterior chamber, hidden behind the limbus, using a slit lamp and a special device - a gonioscope, which is a system of mirrors (Fig. 4.7). Van Beuningen, Goldmann and Krasnov gonioscopes are used.

Gonioscopy allows you to detect various pathological changes in the angle of the anterior chamber (tumors, foreign bodies, etc.). Especially

It is important to determine the degree of openness of the anterior chamber angle, according to which wide, medium width, narrow and closed angles are distinguished.

Rice. 4.7. Gonioscope

Diaphanoscopy and transillumination

Instrumental examination of intraocular structures is carried out by directing light into the eye through the sclera (with diaphanoscopy) or through the cornea (with transillumination) using diaphanoscopes. The method makes it possible to detect massive hemorrhages in the vitreous body (hemophthalmos), some intraocular tumors and foreign bodies.

Echoophthalmoscopy

Ultrasound research method structures of the eyeball are used in ophthalmology to diagnose retinal and choroidal detachment, tumors and foreign bodies. It is very important that echoophthalmography can also be used in cases of opacification of the optical media of the eye, when the use of ophthalmoscopy and biomicroscopy is impossible.

Doppler ultrasound allows you to determine the linear speed and direction of blood flow in the internal carotid and orbital arteries. The method is used for diagnostic purposes for eye injuries and diseases caused by stenotic or occlusive processes in these arteries.

Entoptometry

An idea of ​​the functional state of the retina can be obtained by using entoptic tests(Greek ento- inside, orto- I see). The method is based on the patient’s visual sensations, which arise as a result of the influence of adequate (light) and inadequate (mechanical and electrical) stimuli on the retinal receptive field.

Mechanophosphene- the phenomenon of feeling a glow in the eye when pressing on the eyeball.

Autoophthalmoscopy- a method that allows you to assess the safety of the functional state of the retina in opaque optical environments of the eye. The retina functions if, with rhythmic movements of the diaphanoscope along the surface of the sclera, the patient notices the appearance of visual patterns.

Fluorescein angiography of the retina

This method is based on serial photography of the passage of sodium fluorescein solution through the retinal vessels (Fig. 4.8). Fluorescein angiography can be performed only in the presence of transparent optical media of the ocular

Rice. 4.8.Retinal angiography (arterial phase)

apple In order to contrast the retinal vessels, a sterile 5-10% sodium fluorescein solution is injected into the cubital vein.

VISUAL EXAMINATION IN CHILDREN

When conducting an ophthalmological examination of children, it is necessary to take into account their rapid fatigue and the inability to fix their gaze for a long time.

An external examination in young children (up to 3 years old) is carried out with the help of a nurse who fixes the child’s arms, legs and head.

Visual functions in children under one year of age can be assessed indirectly by the appearance of tracking (end of the 1st and beginning of the 2nd month of life), fixation (2 months of life), danger reflex - the child closes his eyes when an object quickly approaches the eye (2-3 months life), convergence (2-4 months of life). Starting from the age of one year, children's visual acuity is assessed by showing them toys of different sizes from different distances. Children aged three years and older are examined using children's optotype tables.

The boundaries of the visual field in children aged 3-4 years are assessed using an approximate method. Perimetry is used from the age of five. It should be remembered that in children the internal boundaries of the visual field are somewhat wider than in adults.

Intraocular pressure in young children is measured under anesthesia.

Diagnosis of eye diseases is carried out by an ophthalmologist in a specially equipped ophthalmology office.

There are serious eye diseases that have a significant impact on vision. These are cataracts, glaucoma, retinal detachment, and a number of inflammatory and infectious diseases. Early diagnosis and treatment of these diseases is the main way to prevent partial loss of vision and sometimes blindness.

Modern ophthalmology allows you to perform all the necessary studies to make an accurate diagnosis, including the following studies:

• determination of visual acuity (computer and subjective methods);
• examination and determination of the condition of the anterior segment of the eyeball;
• measurement of intraocular pressure;
• fundus examination;
• computer keratotopography (examination of the cornea for accurate diagnosis of astigatism and keratoconus);
• fluorescein digital angiography - computer images of the fundus and examination of retinal vessels for selective treatment of areas of retinal damage (diabetic retinopathy, macular degeneration, etc.);
• complex of electrophysiological studies;
• complex of laboratory tests for preoperative preparation.

Special means for diagnosing eye diseases include: computed tomography of the eye, computer perimetry, ultrasound examination of the eye, topography of the fundus, tonography, determination of color vision, gonioscopy, skiascopy.

Modern diagnostic tools in ophthalmology contribute not only to making an accurate diagnosis, but also allow monitoring and effectively managing the process of treating diseases.

Methods of eye examination in ophthalmology

A comprehensive examination by an ophthalmologist includes the following procedures:

Visometry- This is a measurement of distance visual acuity. In this case, the patient looks at a table with letters, numbers or other signs and names the objects that the ophthalmologist points to. Determination of visual acuity is carried out first without correction, then, if there are violations, with correction (using a special frame and lenses). Decreased vision is an important symptom in the diagnosis of eye diseases.

Tonometry- This is a measurement of intraocular pressure. It can be carried out in several ways (using a pneumotonometer, weights (according to Maklakov), palpation, etc.). This procedure is mandatory for people over 40 years old, because... It is after 40 years that the risk of developing glaucoma increases significantly, which is what this study is aimed at identifying.

Refractometry- this is a determination of the optical power of the eye (refraction). The procedure is currently carried out using automatic refractometers, which greatly facilitates the work of the ophthalmologist and saves the patient’s time. Using this method, refractive errors are diagnosed: myopia, farsightedness and astigmatism.

Color vision testing- this is a method of examining the eyes, carried out using special tables (Rabkin tables) and serves to determine such color vision disorders as protanopia, deuteranopia or color weakness (types of color blindness).

Perimetry is the definition of a person's peripheral vision. The procedure is carried out using special devices, which are a hemisphere, on the inner surface of which light signals are projected. This is an important method for diagnosing eye diseases such as glaucoma, partial optic atrophy, etc.

Biomicroscopy is a method of examining the anterior segment of the eye using a slit lamp (special microscope). Using biomicroscopy, an ophthalmologist can see at high magnification such eye tissues as the conjunctiva, cornea, as well as deeper structures - the iris, lens, vitreous body.

Ophthalmoscopy- this is a study that allows the doctor to see the fundus (inner surface of the eye) - this is the retina, blood vessels. This is one of the most common and important methods in diagnosing eye diseases. The procedure is carried out contactlessly, using a special device - an ophthalmoscope or lens.
Where to get an eye examination

Despite the large number of ophthalmological centers, not all of them have all the necessary equipment and specialists capable of working on it and correctly interpreting the results. One of the few institutions that has the most modern equipment and world-class specialists is the Moscow Eye Clinic. Along with this, affordable prices and impeccable service make this eye clinic one of the best in Russia.

Ophthalmometry- this is a determination of the refractive power of the cornea in different meridians. In this way, the degree of corneal astigmatism can be determined. The study is carried out using a special device - an ophthalmometer.

Determination of the angle of strabismus- this is a fairly simple procedure, an example is the Grishberg method - the patient looks through an ophthalmoscope, and the doctor monitors the reflection of light on his cornea and, depending on this, determines the angle of strabismus.

Probing (bougienage) of the lacrimal canals is a procedure performed for therapeutic purposes, most often in infants, but also in older people, who often experience narrowing of the lacrimal openings. It is performed under local anesthesia using special dilating probes.

Washing the tear ducts- this procedure is carried out for diagnostic purposes if there is a suspicion of obstruction of the lacrimal ducts. It can also be used for medicinal purposes. Special cannulas are inserted into the lacrimal openings on the eyelid, to which a syringe with a solution is attached. If the lacrimal ducts are blocked, the liquid from the syringe enters the nasal cavity, but if there is obstruction of the lacrimal ducts, the liquid pours out or does not pass at all.

As a rule, these methods are quite sufficient to diagnose the most common eye diseases (for example, myopia, conjunctivitis, cataracts, etc.). However, if an ophthalmologist has doubts about the diagnosis, he can use additional methods for diagnosing eye diseases, which require special equipment and are carried out in specialized ophthalmological centers or departments.
Special methods used in the diagnosis of eye diseases

Campimetry- this is the determination of the central field of vision, often in terms of colors. The device for this study is called a campimeter and is a special 2x2 meter screen on which markers are presented to the patient (alternately with the right and left eyes). This method can be used to diagnose eye diseases such as glaucoma, diseases of the retina and optic nerve.

Ultrasound examination of the eyeball (ultrasound)- This is a fairly common research method that has gained popularity due to its efficiency, lack of complications and information content. This study is used to diagnose eye diseases such as retinal detachment, neoplasms of the eye and orbit, and foreign bodies.

Electrophysiological study (EPS)- this allows you to assess the condition of the retina, optic nerve, and cerebral cortex. Those. functions of the entire nervous tissue of the visual apparatus. This method has found wide application in the diagnosis of diseases of the retina and optic nerve.

Tonography is a recording of intraocular pressure (IOP) over time. The procedure takes about 4-5 minutes, but during this time important information about outflow can be obtained.

Keratotopogram is a study showing the surface of the cornea, its “topographic map”. The study is carried out before laser operations on the cornea, if keratoconus and keratoglobus are suspected.

Pachymetry- This is a determination of the thickness of the cornea. This study is mandatory for laser operations.

Fluorescein angiography- this is one of the methods that shows the condition of the retinal vessels. The study is carried out by intravenous administration of a contrast agent and taking a series of images in the retinal vessels.

Examination of eyelashes for demodex- this procedure involves collecting eyelashes followed by examination under a microscope. Depending on the number of mites found, the disease “demodicosis” is diagnosed.

OTC (optical coherence tomography) is optical coherence tomography. Used to assess the condition of the retina and optic nerve. Used in eye examinations for diseases such as retinal dystrophy and detachment, glaucoma, and optic nerve diseases.

Gonioscopy is a procedure in which an ophthalmologist examines the angle of the anterior chamber using a special lens. The study is carried out during examination for glaucoma.

Schirmer test- This is a study that allows you to determine tear production. A special paper strip is placed behind the patient’s lower eyelid, after which it is determined how saturated it is with tears. This test is performed for a disease such as dry eye syndrome.

Fundus examination with Goldmann lens is a method used to evaluate the peripheral parts of the retina that are not visible during normal fundus examination. It is used to diagnose eye diseases such as retinal detachment and dystrophy.