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With an external (general) examination of the patient, features that are directly or indirectly associated with changes in the organ of vision are noted. So, the presence on the face of scars formed after injuries or surgeries, especially in the eyelid, outer and inner corners of the eye gap, may indicate an earlier damage to the eyeball.
The presence on the skin of the forehead and the temporal region of the bubble rash in combination with blepharospasm most often indicates a herpetic lesion of the eyeball. The same combination can be observed with rosacea-keratitis, in which, in addition to severe pain, irritation of the eyeball and corneal damage, skin lesions are noted - rosacea.
In order to establish the correct diagnosis, in general examination it is also important to determine the characteristic external changes in other areas, combined with the pathology of the organ of vision, such as facial asymmetry (in trigeminal neuralgia in combination with neuroparalytic keratitis), unusual body proportions ( brachidactyly ), tower (oxycephaly) or boat-shaped (skafotsefaliya) skull, pchego-eyes ( thyrotoxicosis ). After the completion of this stage, the exams are taken to clarify the patient's complaints and to collect the anamnesis.
Sting analysis and history
An analysis of the patient's complaints makes it possible to establish the nature of the disease: whether it developed acutely or developed gradually. At the same time among the complaints characteristic of many common diseases of the body, it is important to identify complaints that are peculiar only to eye diseases.
Some complaints are so characteristic of this or that eye disease, that on their basis it is already possible to establish a presumptive diagnosis. For example, the sensation of a mote, sand or foreign body in the eye and heaviness of the eyelids indicates the pathology of the cornea or chronic conjunctivitis, and gluing the eyelids in the morning in combination with an abundant discharge from the conjunctival cavity and reddening of the eye without a noticeable decrease in visual acuity indicates the presence of acute conjunctivitis , reddening and itching in the region of the eyelid edges - about the presence of blepharitis. At the same time, it is easy to determine the localization of the process on the basis of some complaints. Thus, photophobia, blepharospasm and abundant lachrymation are typical for cornea lesions and diseases, and suddenly and painlessly comes blindness - for injuries and diseases of the light-receiving apparatus. However, in such cases, the complaint itself does not yet determine the nature of the disease, it is only an initial reference point.
Some complaints, such as blurred vision, are made by patients with cataracts, glaucoma, retinal and optic nerve diseases, hypertension, diabetes, brain tumors, etc. However, only targeted interrogation (clarification of anamnesis and complaints) allows the doctor to establish the correct diagnosis. Thus, the gradual decrease or loss of vision is characteristic of slowly developing pathological processes (cataract, open-angle glaucoma, chorioretinitis, optic nerve atrophy, refractive error ), and the sudden loss of visual functions is associated with circulatory disorders in the retina (spasm, embolism, thrombosis, hemorrhage); acute inflammatory processes (optic neuritis, central horioidity and chorioretinitis), severe trauma, retinal detachment, and others. The sharp decline in visual acuity with severe pain in Ch ZNOM apple characteristic of acute glaucoma attack or acute iridocyclitis.
It is advisable to carry out anamnesis collection step by step. Initially, it is necessary to pay attention to the onset of the disease, to ask the patient about the cause of the onset and the dynamics of the disease, the treatment and its effectiveness. It is necessary to find out the nature of the disease: a sudden onset, acute or slow developing, chronic, arising under the influence of unfavorable external factors. For example, an acute attack of glaucoma can occur against the background of emotional overload, prolonged stay in a dark room, overwork or hypothermia. Chronic diseases of the vascular tract (irites, iridocyclitis, chorioretinitis) may be associated with hypothermia and weakened immunity. Inflammatory infiltrates and purulent corneal ulcers occur against the background of previous traumatic injuries, hypothermia, after the common infectious diseases.
If congenital or hereditary pathology is assumed, then a family history is clarified, this refers to zonal cataract, hydrophthalmus, syphilitic keratitis or, for example, familial atrophy of the optic nerve, familial amaurotic idiocy.
It is necessary to ask the patient about the conditions of his work and life, since some diseases of the organ of vision can be associated with the impact of occupational hazards: brucellosis in agricultural workers, progressive myopia in patients who have a constant visual load under unfavorable working conditions, electro-ophthalmia in electric welders, e.
Exterior examination of the eye
First of all, pay attention, are the eyes the same size? Look, whether the eyelids are symmetrical and whether their retraction is normal when looking up. Ptosis is the descent of the upper eyelid and the absence of normal retraction when looking up. Look, is not the conjunctiva inflamed? Examine the cornea with a magnifying glass - are there any scratches on it? If you suspect a scratch, insert a fluorescein solution in your eye to fix defects in the corneal epithelium.
Exterior examination is carried out with good daylight or artificial light and begin with an assessment of the shape of the head, face, condition of the auxiliary eye organs. First of all, assess the state of the eye gap: it can be narrowed by photophobia, closed with swollen eyelids, greatly expanded, shortened in the horizontal direction (blepharophimosis), not completely closed ( lagophthalmus ), irregularly shaped (eyelid turn or turn, dacryoadenitis ), closed on sites of fusion of the edges of the eyelids (ankiloblepharon). Then the condition of the eyelids is evaluated, in this case, the partial or complete lowering of the upper eyelid (ptosis), the defect (coloboma) of the free edge of the eyelid, the growth of the eyelashes towards the eyeball ( trichiasis ), the presence of a vertical cutaneous fold at the angle of the eyelid / ( epicanthus ), turn or turn of the ciliary margin.
When examining the conjunctiva, severe hyperemia without hemorrhage ( bacterial conjunctivitis ), hyperemia with hemorrhages and abundant discharge ( viral conjunctivitis ) can be determined . In patients with pathology of lacrimal organs, one can note tearfulness.
When inflammation of the lacrimal sac or tubules is found mucous, mucopurulent or purulent discharge, the appearance of purulent discharge from 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 eye gap indicate dacryoadenitis.
Further, the state of the eyeball as a whole is assessed: its absence ( anophthalmus ), occlusion ( enophthalmus ), distance from the orbit ( exophthalmos ), deviation away from the fixation point ( strabismus ), increase (bufalm) or decrease (microphthalmia), redness (inflammatory diseases or ophthalmic hypertension), yellowish ( hepatitis ) or bluish (Van der Huve syndrome or blue sclera syndrome ), as well as the state of the orbit: deformation of the bone walls (the effects of trauma), the presence of swelling and additional tissue (tumor, cyst, heme atom).
It should be borne in mind that the diseases of the organ of vision are characterized by the variety and originality of clinical manifestations. For their recognition, an attentive examination of both the healthy and the diseased eye is necessary. The study is carried out in a certain sequence: first assess the condition of the auxiliary organs of the eye, then examine its anterior and posterior parts. At the same time, they always begin with an examination and instrumental examination of a healthy eye.
The study of the orbit and surrounding tissues begins with an examination. First of all, they examine the part of the face surrounding the orbit. Particular attention is paid to the position and mobility of the eyeball, the change of which may serve as an indirect sign of the pathological process in the orbit (tumor, cyst, hematoma, traumatic deformity).
When determining the position of the eyeball in orbit, the following factors are evaluated: the degree of its standing or twisting (exophthalmometry), the deviation from the midline (strobometry), the magnitude and ease of displacement into the orbit cavity under the influence of the metered pressure (orbitotonometry).
Exophthalmometry - an estimate of the degree of distension (obscuration) of the eyeball from the bone orbit ring. The study is carried out using the Gertel mirror exophthalmometer, which is a graduated horizontal plate in millimeters, with two mirrors crossed at an angle of 45 ° on each side. The device is tightly attached to the outer arcs of both orbits. In this case, the top of the cornea is seen in the lower mirror, and in the upper mirror there is a figure indicating the distance to which the image of the apex of the cornea is separated from the application point. Be sure 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 carrying out exophthalmometry in dynamics. Normally, the eyeball is 14-19 mm from the orbit and the asymmetry in the pair eye position should not exceed 1-2 mm.
Necessary measurements of the eyeball's distances can be made using a conventional millimeter ruler, which is placed strictly perpendicular to the outer edge of the orbit, while the patient's head is turned in profile. The magnitude of the distance is determined by the division, which is at the level of the apex of the cornea.
Orbitotonometry is the determination of the degree of displacement of the eyeball in the orbit or the compressibility of retrobulbar tissues. The method allows to differentiate the tumor and non-tumor exophthalmos. The study is carried out using a special device - a piezometer, which consists of a crossbar with two stops (for the outer corner of the orbit and the back of the nose), and the dynamometer itself with a set of change weights mounted on the eye, covered with a contact corneal lens. Orbitotonometry is performed in the supine position after preliminary drip anesthesia of the eyeball with a solution of dicaine. Having installed and fixed the device, proceed to measurement, consistently increasing the pressure on the eyeball (50, 100, 150, 200 and 250 g). The value of the displacement of the eyeball (in millimeters) is determined by the formula: V = E0 - Em
Where V is the displacement of the eyeball under the reponning force; E0 is the starting position of the eyeball; Em - the position of the eyeball after applying the reponant force.
A normal eyeball with an increase in pressure for every 50 g is repaired by approximately 1.2 mm. At a pressure of 250 g, it is displaced by 5-7 mm.
Strabometry is the measurement of the angle of deflection of a mowing eye. The study is conducted using various methods, both indicative - according to Hirschberg and Lawrence, and accurate enough - according to Golovin.
The eyelids are examined by means of routine examination and palpation, paying attention to their shape, position and direction of eyelash growth, the condition of the ciliary margin, skin and cartilage, eyelid mobility and width of the eye gap. The width of the ocular gap is, on average, 12 mm. Its change may be due to the different size of the eyeball and its displacement forward or backward, with the descent of the upper eyelid.
Study of the connective membrane (conjunctiva)
The conjunctiva lining the lower eyelid, easily turns out when it is pulled down. Thus the patient should look upwards. Alternately pull the inner and outer edges, inspect the conjunctiva of the century and the lower transition fold.
To turn the upper eyelid requires a certain skill. He is twisted with his fingers, and to examine the upper transitional fold use a glass rod or eyeliner. When the patient looks down the thumb of the left hand lifts the upper eyelid. With the thumb and forefinger of the right hand, grab the ciliary edge of the upper eyelid, pull it downwards and anteriorly. In this case, under the skin of the eyelid, the upper edge of the cartilaginous plate is delineated, which is pressed with the thumb of the left hand or with a glass rod. And fingers of the right hand at this moment start up the lower edge of the century 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 quite often localized various foreign bodies that cause sharp pain and irritation of the eyeball, it is necessary to push slightly through the lower eyelid to the eyeball upward. Even better is the examination of the upper transitional fold with the help of the eyelid: its edge is put on the skin at the upper edge of the cartilage slightly pulled downwards and twisted it, pulling it towards the end of the eyelid. After the inversion of the eyelid, the ciliary edge is held with the thumb of the left hand at the edge of the orbit.
The normal conjunctiva of the eyelids are pale pink, smooth, transparent, moist. Through it are visible meibomian glands and their ducts, located in the thickness of the cartilaginous plate perpendicular to the edge of the eyelid. Normally, the secret is not defined in them. It appears, if you squeeze the edge of the century between your finger and a glass rod.
The vessels are clearly visible in the transparent conjunctiva.
Investigation of lacrimal organs
Examination of lacrimal organs is carried out by examination and palpation. When pulling the upper eyelid and a quick glance of the patient to the inside, they examine the palpebral part of the lacrimal gland. Thus, it is possible to identify the omission of the lacrimal gland, its tumor or inflammatory infiltration. With palpation, one can determine soreness, swelling, and compaction of the orbital part of the gland in the region of the upper-outer corner of the orbit.
The condition of the tear ducts is determined by examination, which is carried out simultaneously with the examination of the position of the eyelids. Evaluate the filling of the lacrimal brook and lake, at the inner corner of the eye the position and magnitude of lacrimal points, the skin condition in the area of the lacrimal sac. Presence of purulent contents in the lacrimal sac is determined by pressing under the inner adhesion of the eyelids from below upwards with the index finger of the right hand. At the same time, the lower eyelid is pulled out with your left hand to see the effusion of the lacrimal sac. Normally, the lacrimal sac is empty. The contents of the lacrimal sac are squeezed through the tear ducts and lacrimal points. In cases of product disruption and lacrimal fluid discharge, special functional tests are performed.
It is especially important to investigate them with diplopia. Ask the patient to follow the tip of the pencil while moving it in the horizontal and vertical planes. Avoid extreme and sharp movements of the eyes, as it is impossible to achieve a fixation of the sight, which simulates nystagmus.
It reflects the central vision and does not reveal violations in the fields of vision.
Always examine visual acuity, as a sudden loss of vision is a formidable symptom. It is ideal to use the Snellen table, but a simple test can be used, such as reading a book with a small font - in the case of pathology, near vision is more likely to suffer than a distant one. A patient who can not read line No. 5 even wearing glasses or using a stenopic hole requires specialist advice. The Snellen table is read from a distance of 6 m with each eye separately. A fully and correctly read last line in this table indicates visual acuity in the distance for this eye. The Snellen table is arranged so that the upper 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. The visual acuity is expressed as follows way: 6/60, 6/36, 6/24, 6/12 or 6/6 (the latter indicates that the subject has normal vision) and depends on the lines read by the patient. Persons who usually wear glasses should be checked in their glasses. If the patient has not brought glasses with him, then check the acuity of his vision, using a stenopic hole in order to reduce the error of refraction. If visual acuity is worse than 6/60, the patient can be brought closer to the table at the distance from which he can read a number of upper letters (for example, at a distance of 4 m), and then the acuity of his vision will be expressed as 4/60. There are other methods for determining visual acuity, for example, the count of the fingers of the hand from a distance of 6 m, and if the vision is even weaker, then only the perception of light is noted. Also determine near vision, using a standard print, which is read from a distance of 30 cm.
Fields of vision
Ask the patient to fix a look at the doctor's nose, and then from different sides enter into the field of view the finger or the tip of the hat with a red head. The patient at the same time informs the doctor when he starts to see this object (the other eye is covered with a napkin). Comparing the patient's field of vision with his fields of vision, it is possible, though rudely, to reveal defects in the patient's fields of vision. Carefully draw the patient's field of vision on the corresponding map. In this case, the size of the blind spot must also be marked.
This method gives an idea of the parts of the eye behind the iris. Stand next to the patient (side of him). The patient fixes his eyes on the object convenient for him. The doctor's right eye examines the right eye, and the left eye examines the left eye. Start the examination in such a way as to reveal the turbidity of the lens. The normal eye gives a red gleam (red reflex), until the retina is focused. The red reflex is absent at dense cataracts and a hemorrhage in an eye. When you manage to focus the retina, carefully inspect the optic nerve disc (it should have clear edges with a central depression). Note whether there is a pallor or swelling of the optic disc. To inspect the radially divergent vessels and the macula (macula), dilate the pupil, while asking the patient to look at the light.
Research with a slit lamp
It is usually performed in hospitals and clearly reveals the presence of deposits (accumulations of different masses) in the anterior and posterior chambers of the eye. Tonometric devices allow measuring the intraocular pressure.
Conditions for successful ophthalmoscopy
- Make sure that the batteries are charged.
- Darken the room as much as possible.
- Take off your glasses and ask the patient to remove the glasses and select the appropriate lenses to correct refractive errors (- the lenses correct myopia, + the lenses correct the hypermetropia).
- If the patient has a sharp myopia or no lens, then ophthalmoscopy is carried out without removing the glasses from the patient. The disc of the optic nerve will appear very small at the same time.
- If it is difficult for you to conduct ophthalmoscopy with a nondeminant eye, try to dominate the eye in both eyes of the patient with the dominant eye ; while you are standing behind the sitting patient, the patient's neck is completely unbent. Before examining the fundus, always check once again the transparency of the lenses you use.
- Always be as close to the patient as possible, despite the fact that one of you used garlic during lunch.
- Think about the use of a short-range mydriatic to expand the pupil.
- Remember that retinal gaps most often occur on the periphery and are difficult to see without special equipment, despite the dilated pupil.
Features of the study of the organ of vision in children
When studying the organ of vision in children, it is necessary to take into account the characteristics of the child's nervous system, its reduced attention, the impossibility of long fixation of the gaze at some particular object.
So, external (external) examination, especially in children under 3 years of age, is better spent together with a nurse who, if necessary, fixes and presses the arms and legs of the child.
Eversion of the eyelids is carried out by pressing, pulling and displacing them towards each other.
Examination of the anterior section of the eyeball is carried out with the help of eyelid lifters after a preliminary drip anesthesia with a solution of dicaine or novocaine. At the same time, the same sequence of examination is observed as in the examination of adult patients.
A study of the posterior eyeball in patients of the youngest age is convenient with an electric ophthalmoscope.
The process of studying the severity and field of vision must be given the nature of the game, especially in children aged 3-4 years.
The boundaries of the field of view at this age are advisable to be determined with the help of an orienting method, but instead of the fingers of the child's hand it is better to show toys of different colors.
The study using instruments has become quite reliable since about 5 years, although in each specific case it is necessary to take into account the characteristics of the child.
Carrying out the study of the field of vision in children, it must be remembered 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 (behind the tendon of the upper rectus muscle).
At the same time, the ends of the tool should not deform the eyeball, otherwise the accuracy of the investigation decreases. In connection with this, the ophthalmologist is forced to monitor the data obtained by tonometry, performing a palpation study of the tone of the eyeball in the equatorial region.