Eye examination

During an external (general) examination of the patient, features are noted that are directly or indirectly related to changes in the organ of vision. Thus, the presence of scars on the face that formed after injuries or operations, especially in the area of the eyelids, the outer and inner corners of the eye slit, may indicate previous damage to the eyeball.

The presence of vesicular rashes on the skin of the forehead and temporal region in combination with blepharospasm most often indicates a herpetic lesion of the eyeball. The same combination can be observed in rosacea keratitis, in which, in addition to severe pain, irritation of the eyeball and damage to the cornea, there is damage to the skin of the face - rosacea.

In order to establish the correct diagnosis, during the general examination it is also important to determine the characteristic external changes in other areas that are combined with the pathology of the visual organ, such as, for example, facial asymmetry (in trigeminal neuralgia combined with neuroparalytic keratitis), unusual body proportions ( brachydactyly ), tower-shaped (oxycephaly) or boat-shaped (scaphocephaly) skull, exophthalmos ( thyrotoxicosis ). After completing this stage of the examination, they move on to clarifying the patient's complaints and collecting anamnesis.

Analysis of complaints and collection of anamnesis

An analysis of the patient's complaints allows us to establish the nature of the disease: whether it arose acutely or developed gradually. At the same time, among the complaints characteristic of many general diseases of the body, it is important to single out complaints characteristic only of eye diseases.

Some complaints are so characteristic of a particular eye disease that they can be used to establish a tentative diagnosis. For example, a sensation of a speck, sand or foreign body in the eye and heaviness of the eyelids indicate a corneal pathology or chronic conjunctivitis, and sticking of the eyelids in the morning combined with abundant discharge from the conjunctival cavity and redness of the eye without a noticeable decrease in visual acuity indicates acute conjunctivitis, redness and itching in the area of the edges of the eyelids - the presence of blepharitis. At the same time, based on some complaints, it is easy to determine the localization of the process. Thus, photophobia, blepharospasm and profuse lacrimation are characteristic of damage and diseases of the cornea, and sudden and painless blindness - for damage and diseases of the light-perceiving apparatus. However, in such cases, the complaint itself does not yet allow us to determine the nature of the disease, it is only an initial guide.

Some complaints, such as blurred vision, are presented by patients with cataracts, glaucoma, diseases of the retina and optic nerve, hypertension, diabetes, brain tumors, etc. However, only targeted questioning (clarification of the anamnesis and complaints) allows the doctor to establish the correct diagnosis. Thus, gradual decrease or loss of vision is characteristic of slowly developing pathological processes (cataract, open-angle glaucoma, chorioretinitis, optic nerve atrophy, refractive errors ), and sudden loss of visual functions is associated with circulatory disorders in the retina (spasm, embolism, thrombosis, hemorrhage), acute inflammatory processes (optic neuritis, central choroiditis and chorioretinitis), severe injuries, retinal detachment, etc. A sharp decrease in visual acuity with severe pain in the eyeball is characteristic of an acute attack of glaucoma or acute iridocyclitis.

It is advisable to collect anamnesis in stages. Initially, it is necessary to pay attention to the onset of the disease, ask the patient about the suspected cause of the disease and its dynamics, the treatment provided and its effectiveness. It is necessary to find out the nature of the disease: sudden onset, acute or slowly developing, chronic, caused by adverse external factors. For example, an acute attack of glaucoma can occur due to emotional overload, prolonged stay in a dark room, fatigue or hypothermia. Chronic diseases of the vascular tract (iritis, iridocyclitis, chorioretinitis) can be associated with hypothermia and weakened immunity. Inflammatory infiltrates and purulent ulcers of the cornea occur due to previous traumatic injuries, hypothermia, after general infectious diseases.

If a congenital or hereditary pathology is suspected, then the family history is clarified, this concerns zonular cataract, hydrophthalmos, syphilitic keratitis or, for example, familial optic atrophy, familial amaurotic idiocy.

It is necessary to ask the patient about his working and living conditions, since some diseases of the visual organ may be associated with exposure to occupational hazards: brucellosis in agricultural workers, progressive myopia in patients with constant visual stress under unfavorable working conditions, electrophthalmia in electric welders, etc.

External examination of the eye

First of all, pay attention to whether the eyes are the same size. Look at whether the eyelids are symmetrical and whether their retraction is normal when looking up. Ptosis is a drooping of the upper eyelid and the absence of normal retraction when the eye looks up. Look to see if the conjunctiva is inflamed. Examine the cornea with a magnifying glass - are there any scratches on it? If you suspect scratches, inject 1% fluorescein into the eye to detect defects in the corneal epithelium.

An external examination is performed in good daylight or artificial light and begins with an assessment of the shape of the head, face, and the condition of the auxiliary organs of the eye. First of all, the condition of the palpebral fissure is assessed: it may be narrowed due to photophobia, closed by swollen eyelids, significantly widened, shortened in the horizontal direction (blepharophimosis), not closed completely ( lagophthalmos ), have an irregular shape (eversion or inversion of the eyelid, dacryoadenitis ), closed at the fusion sites of the eyelid margins (ankyloblepharon). Then the condition of the eyelids is assessed, which may reveal partial or complete drooping of the upper eyelid (ptosis), a defect (coloboma) of the free edge of the eyelid, growth of eyelashes towards the eyeball ( trichiasis ), the presence of a vertical skin fold at the corner of the eyelid / ( epicanthus ), inversion or eversion of the ciliary margin.

When examining the conjunctiva, severe hyperemia without hemorrhage ( bacterial conjunctivitis ), hyperemia with hemorrhage and abundant discharge ( viral conjunctivitis ) can be determined. In patients with pathology of the lacrimal organs, lacrimation can be noted.

In case of inflammation of the lacrimal sac or canals, mucous, mucopurulent or purulent discharge is detected, the appearance of purulent discharge from the lacrimal points when pressing on the area of the lacrimal sac ( dacryocystitis ). Inflammatory swelling of the outer part of the upper eyelid and S-shaped curvature of the palpebral fissure indicate dacryoadenitis.

Next, the condition of the eyeball as a whole is assessed: its absence ( anophthalmos ), recession ( enophthalmos ), protrusion from the orbit ( exophthalmos ), deviation to the side from the fixation point ( strabismus ), enlargement (buphthalmos) or reduction (microphthalmos), redness (inflammatory diseases or ophthalmic hypertension), yellowish ( hepatitis ) or bluish (Van der Hoeve syndrome or blue sclera syndrome ) coloration, as well as the condition of the orbit: deformation of the bone walls (consequences of injury), the presence of swelling and additional tissue (tumor, cyst, hematoma).

It should be taken into account that diseases of the visual organ are characterized by a variety and uniqueness of clinical manifestations. To recognize them, a careful examination of both the healthy and the diseased eye is necessary. The study is carried out in a certain sequence: first, the condition of the auxiliary organs of the eye is assessed, then its anterior and posterior sections are examined. In this case, they always begin with an examination and instrumental study of the healthy eye.

The examination of the orbit and surrounding tissues begins with an examination. First of all, the parts of the face surrounding the eye socket are examined. Particular attention is paid to the position and mobility of the eyeball, a change in which can serve as an indirect sign of a pathological process in the orbit (tumor, cyst, hematoma, traumatic deformation).

When determining the position of the eyeball in the orbit, the following factors are assessed: the degree of its protrusion or recession (exophthalmometry), deviation from the midline (strabometry), the magnitude and ease of displacement into the orbital cavity under the influence of dosed pressure (orbitotonometry).

Exophthalmometry is an assessment of the degree of protrusion (retraction) of the eyeball from the bony ring of the orbit. The study is conducted using a Hertel mirror exophthalmometer, which is a horizontal plate graduated in millimeters, on each side of which there are 2 mirrors crossing at an angle of 45°. The device is tightly placed against the outer arcs of both orbits. In this case, the apex of the cornea is visible in the lower mirror, and in the upper one - a number indicating the distance at which the image of the apex of the cornea is from the point of application. It is imperative to take into account the initial basis - the distance between the outer edges of the orbit, at which the measurement was made, which is necessary for conducting exophthalmometry in dynamics. Normally, the protrusion of the eyeball from the orbit is 14-19 mm, and the asymmetry in the position of the paired eyes should not exceed 1-2 mm.

The necessary measurements of the protrusion of the eyeball can also be taken using a regular millimeter ruler, which is placed strictly perpendicular to the outer edge of the eye socket, with the patient's head turned in profile. The protrusion value is determined by the division, which is at the level of the apex of the cornea.

Orbitotonometry is a method for determining the degree of displacement of the eyeball in the orbit or the compressibility of the retrobulbar tissues. The method allows differentiating between tumor and non-tumor exophthalmos. The study is conducted using a special device - a piezometer, which consists of a crossbar with two stops (for the outer angle of the orbit and the bridge of the nose), and a dynamometer with a set of replaceable weights installed on the eye covered with a contact corneal lens. Orbitotonometry is performed in a lying position after preliminary drop anesthesia of the eyeball with a dicaine solution. After installing and fixing the device, they begin measuring, sequentially increasing the pressure on the eyeball (50, 100, 150, 200 and 250 g). The magnitude of the displacement of the eyeball (in millimeters) is determined by the formula: V = E0 - Em

Where V is the displacement of the eyeball during the repositioning force; E0 is the initial position of the eyeball; Em is the position of the eyeball after the application of the repositioning force.

A normal eyeball repositions approximately 1.2 mm with every 50 g increase in pressure. With 250 g pressure, it moves 5-7 mm.

Strabometry is the measurement of the angle of deviation of the squinting eye. The study is conducted using various methods, both approximate - according to Hirschberg and Lawrence, and quite accurate - according to Golovin.

The eyelids are examined by means of a regular inspection and palpation, paying attention to their shape, position and direction of eyelash growth, condition of the ciliary margin, skin and cartilage, eyelid mobility and the width of the palpebral fissure. The width of the palpebral fissure is on average 12 mm. Its change may be associated with different sizes of the eyeball and its forward or backward displacement, with drooping of the upper eyelid.

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Examination of the conjunctiva

The conjunctiva lining the lower eyelid is easily everted when it is pulled down. The patient should look up. The inner and outer edges are pulled alternately, the conjunctiva of the eyelid and the lower transitional fold are examined.

A certain skill is required to evert the upper eyelid. It is everted with the fingers, and a glass rod or eyelid lifter is used to examine the upper transitional fold. With the patient looking down, the upper eyelid is lifted with the thumb of the left hand. The thumb and index finger of the right hand grasp the ciliary edge of the upper eyelid, pulling it down and forward. At the same time, the upper edge of the cartilaginous plate is outlined under the skin of the eyelid, which is pressed with the thumb of the left hand or a glass rod. At this moment, the fingers of the right hand move the lower edge of the eyelid upward and intercept it with the thumb of the left hand, fix it by the eyelashes and press it to the edge of the orbit. The right hand remains free for manipulation.

In order to examine the upper transitional fold, where various foreign bodies are often localized, causing sharp pain and irritation of the eyeball, it is necessary to press lightly upward on the eyeball through the lower eyelid. An even better way to examine the upper transitional fold is with an eyelid lifter: its edge is placed on the skin at the upper edge of the cartilage of the slightly pulled down eyelid and is turned inside out, pulling it onto the end of the eyelid lifter. After everting the eyelid, the ciliary edge is held by the thumb of the left hand at the edge of the orbit.

The normal conjunctiva of the eyelids is pale pink, smooth, transparent, and moist. The meibomian glands and their ducts are visible through it, located in the thickness of the cartilaginous plate perpendicular to the edge of the eyelid. Normally, no secretion is detected in them. It appears if you squeeze the edge of the eyelid between your finger and a glass rod.

The vessels are clearly visible in the transparent conjunctiva.

Examination of the lacrimal organs

The lacrimal organs are examined by inspection and palpation. When the upper eyelid is pulled back and the patient quickly looks inward, the palpebral part of the lacrimal gland is examined. In this way, it is possible to detect ptosis of the lacrimal gland, its tumor or inflammatory infiltration. When palpating, it is possible to determine pain, swelling, compaction of the orbital part of the gland in the area of the upper-outer angle of the orbit.

The condition of the lacrimal ducts is determined by inspection, which is carried out simultaneously with the examination of the position of the eyelids. The filling of the lacrimal rivulet and lake, the position and size of the lacrimal points at the inner corner of the eye, and the condition of the skin in the area of the lacrimal sac are assessed. The presence of purulent contents in the lacrimal sac is determined by pressing under the inner commissure of the eyelids from the bottom up with the index finger of the right hand. At the same time, the lower eyelid is pulled down with the left hand to see the poured out contents of the lacrimal sac. Normally, the lacrimal sac is empty. The contents of the lacrimal sac are squeezed out through the lacrimal canaliculi and lacrimal points. In cases of impaired production and drainage of lacrimal fluid, special functional tests are carried out.

Pupils

The pupils should be the same size. They should contract when a beam of light is directed into the eye, as well as when looking at a nearby object ( accommodation ).

Extraocular movements

It is especially important to examine them in diplopia. Ask the patient to follow the tip of a pencil with his eyes as it moves in the horizontal and vertical planes. Avoid extreme and abrupt eye movements, as this makes it impossible to achieve gaze fixation, which simulates nystagmus.

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Visual acuity

It reflects central vision and does not reveal any disturbances in the visual fields.

Always examine visual acuity, as sudden loss of vision is a serious symptom. Ideally, the Snellen chart should be used, but a simple test such as reading a book with small print can also be used - in case of pathology, near vision suffers more often than distant vision. A patient who cannot read line #5 even with glasses or using a stenopic aperture requires a specialist consultation. The Snellen chart is read from a distance of 6 m with each eye separately. The last line in this chart, fully and correctly read, indicates the visual acuity at a distance for this eye. The Snellen chart is positioned so that the top row of letters can be read by a person with normal vision from a distance of 60 m, the second line from 36 m, the third from 24 m, the fourth from 12 m and the fifth from 6 m. Visual acuity is expressed as follows: 6/60, 6/36, 6/24, 6/12 or 6/6 (the last indicates that the subject has normal vision) and depends on the lines read by the patient. Persons who usually wear glasses should have their visual acuity tested using their glasses. If the patient has not brought glasses with them, their visual acuity should be tested using the stenopic opening in order to reduce the refractive error. If visual acuity is worse than 6/60, the patient can be brought closer to the chart to a distance from which he can read a row of upper letters (for example, at a distance of 4 m), and then his visual acuity will be expressed as 4/60. There are other methods for determining visual acuity, for example, counting fingers from a distance of 6 m, and if vision is even weaker, then only the patient's perception of light is noted. Near vision is also determined using a standard print, which is read from a distance of 30 cm.

Fields of view

Ask the patient to fix his gaze on the doctor's nose, and then insert a finger or the tip of a hat needle with a red head into the field of vision from different sides. The patient tells the doctor when he begins to see this object (the other eye is covered with a napkin). By comparing the patient's fields of vision with your own, you can, albeit roughly, identify defects in the patient's fields of vision. Carefully draw the patient's fields of vision on the appropriate map. The size of the blind spot should also be noted.

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Ophthalmoscopy

This method gives an idea of the parts of the eye located behind the iris. Stand next to the patient (to the side). The patient fixes his gaze on an object convenient for him. The doctor examines the patient's right eye with the right eye, and the left eye with the left eye. Begin the examination in such a way as to detect opacities of the lenses. A normal eye gives a red gleam (red reflex) until the retina is focused. The red reflex is absent in dense cataracts and hemorrhage into the eye. When you succeed in focusing the retina, carefully examine the optic disc (it should have clear edges with a central depression). Note whether the optic disc is pale or swollen. To examine the radiating vessels and the yellow spot (macula), dilate the pupil, while asking the patient to look at the light.

Slit lamp examination

It is usually performed in hospitals and clearly reveals the presence of deposits (accumulations of various masses) in the anterior and posterior chambers of the eye. Tonometric devices allow measuring intraocular pressure.

Conditions for successful ophthalmoscopy

• Make sure the batteries are charged.
• Darken the room as much as possible.
• Remove glasses and ask the patient to remove glasses and select appropriate lenses to correct refractive errors (- lenses correct myopia, + lenses correct hyperopia).
• If the patient has severe myopia or no lens, ophthalmoscopy is performed without removing the patient's glasses. The optic disc will appear very small.
• If you have difficulty performing ophthalmoscopy with your non-dominant eye, try examining the fundus in both of the patient's eyes with your dominant eye; stand behind the seated patient with the patient's neck fully extended. Always double-check the clarity of the lenses you are using before examining the fundus.
• Always stay as close as possible to the patient, even if one of you ate garlic during lunch.
• Consider using a short-acting mydriatic to dilate the pupil.
• Remember that retinal tears most often occur in the periphery and are difficult to see without special equipment, despite a dilated pupil.

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Peculiarities of examination of the visual organ in children

When examining the visual organ in children, it is necessary to take into account the characteristics of the child’s nervous system, his decreased attention, and the inability to fix his gaze on a specific object for a long time.

Thus, an external (outer) examination, especially in children under 3 years of age, is best carried out together with a nurse, who, if necessary, fixes and presses the child’s arms and legs.

Eversion of the eyelids is achieved by pressing, pulling and moving them towards each other.

Examination of the anterior part of the eyeball is performed using eyelid lifters after preliminary drop anesthesia with a solution of dicaine or novocaine. The same sequence of examination is observed as when examining adult patients.

Examination of the posterior segment of the eyeball in very young patients is conveniently performed using an electric ophthalmoscope.

The process of studying visual acuity and field of vision should be given the character of a game, especially in children aged 3-4 years.

At this age, it is advisable to determine the boundaries of the visual field using the orientation method, but instead of fingers, it is better to show the child toys of different colors.

Research using devices becomes quite reliable from about 5 years of age, although in each specific case it is necessary to take into account the child’s characterological features.

When examining the visual field in children, it is important to remember that its internal boundaries are wider than in adults.

Tonometry in small and restless children is performed under mask anesthesia, carefully fixing the eye in the desired position with microsurgical tweezers (by the tendon of the superior rectus muscle).

In this case, the ends of the instrument should not deform the eyeball, otherwise the accuracy of the study decreases. In this regard, the ophthalmologist is forced to control the data obtained during tonometry, conducting a palpatory study of the tone of the eyeball in the equator area.

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