Plan:
1.Topicality of the problem.
2.Etiology, pathogenesis, manifestations, effects on the patient of keratitis.
3.General symptomatology of corneal diseases. Corneal erosion: clinical symptoms, principles of treatment.
4.Purulent corneal ulcer: etiology, clinic, emergency care, principles of treatment.
5.Scleritis.Symptoms.Diagnosis.Treatment.
Glaucoma. Etiology, clinic.
7. The main types of glaucoma.
Risk factors of glaucoma development. Clinic of open and closed angle glaucoma.
9. Intraocular pressure in norm and pathology. Principles of diagnostics, treatment and prophylaxis of glaucoma. The importance of early diagnosis.
10.Symptomatology and emergency treatment of acute attack of glaucoma.
11. cataract. Etiology, clinic, diagnosis principles, treatment. 10.Classification of cataracts according to time of origin, anatomic and etiological features.
12. Age-related cataract: clinical picture, treatment principles.
13.Aphakia, methods of correction.
Glaucoma is one of the modern socially significant problems which, in spite of a colossal technical breakthrough, remains an incurable disease. It’s impossible to cure it completely, but it can be prevented!
According to statistics from the Ministry of Health, the number of glaucoma patients in Russia has increased since 2013. Then there were 823.8 cases per 100 thousand people, in 2018 – 909.9. According to statistics from the Ministry of Health, the number of patients with glaucoma in Russia has increased since 2013. At that time, 823.8 cases of the disease per 100 thousand people were registered, in 2018 – 909.9.
The most frequent cause of curable blindness in the world is cataract, the share of which, according to the WHO, is 47% of the total eye morbidity. Age-related cataract ranks among the leading causes of blindness and low vision in the world. Cataract dominates everywhere among the causes of reversible blindness and visual impairment and, due to its high prevalence, is considered not only as one of the most important problems of ophthalmology but also as a major world medical and social problem.
KERATITES.
Keratitis is an inflammatory disease of the cornea membrane caused by traumas, bacterial and viral infections, fungi, chronic diseases (tuberculosis, syphilis, etc.), avitaminosis and dystrophic changes. Keratitis is a serious disease and may lead to permanent vision loss due to corneal opacity (corneal veins), adhesions in the pupil area, etc. In severe cases endophthalmitis and panophthalmitis may develop (see). The duration of the disease may be several weeks or months. Superficial catarrhal keratitis (marginal). It occurs against the background of conjunctivitis, blepharitis, chronic dacryocystitis. There is photophobia, lacrimation, pain in the eye. The conjunctiva around the cornea becomes red. Single or confluent infiltrates appear along the corneal margin which may ulcerate. Later the cornea becomes infiltrated with blood vessels. This keratitis is characterized by long-term course without pronounced dynamics.
Treatment. The first step is to eliminate the main cause of the disease. Topical solutions: penicillin, 1% tetracycline, 0.25% levomycetin, 0.5% gentamicin, 20-30% sulfacyl-sodium, 10-20% sulfapyridazine-sodium. Ointments: 1% tetracycline, 1% erythromycin, 1% synthomycin emulsion, actovegin, solcoseryl. Solutions to dilate the pupil: 1% homatropine, 1% platifylline hydrotartrate. Vitamin drops – citral, glucose. Hydrocortisone solution – carefully. Inside: 10 % solution of calcium chloride, dimedrol, pipolphene, suprastin. CREEPING CORNEAL ULCER. Most often occurs after trauma or micro trauma of the cornea. The onset is acute. Severe pain in the eye, photophobia, lacrimation, purulent discharge occur. The conjunctiva is red, edematous. The cornea has a grayish-yellow infiltrate which quickly ulcerates. A defect forms, one edge of which looks undermined; the process begins to spread to the healthy tissue. A level of pus (hypopyon) is detected in the anterior chamber. The process may rapidly engulf the inner membranes of the eye. Corneal perforation (rupture) is possible. Even with a favorable outcome, persistent opacity remains. Treatment. In-patient treatment is obligatory. Topical: frequent solution drops of antibiotics, sulfonamides, and drugs to dilate the pupil. Antibiotics are injected under the conjunctiva. General treatment: intramuscular, intravenous antibiotics, oral sulfonamides, desensitizing agents. In severe cases, cryoapplication (i.e., at low temperature, minus 90-180bC), diathermic coagulation (high frequency current), quenching with 10% alcohol iodine solution, covering ulcers with biologically active tissues (conjunctiva, placenta, donor cornea) are performed.
SCLERITIS.
Inflammatory disease of the sclera of different origin.
Symptoms and course. A limited red-purple swelling appears on the sclera between the cornea and the equator of the eye. Palpation of this place is sharply painful, photophobia and lacrimation are possible. Sometimes keratitis or iridocyclitis join (see). Both eyes are usually affected. The process may occupy a large surface area. If the iris is involved, secondary glaucoma may join as a result of constriction of the pupil. Sometimes the inflammation turns purulent: a purulent infiltration occurs in the place of the swelling which opens through the conjunctiva. Scleritis is prone to recurrences which can result in the development of the sclera bulging which in its turn can lead to loss of vision or retinal detachment. Recognition. If scleritis is suspected, a doctor should be consulted. It is caused by systemic diseases, allergies, viral lesions, chronic infections (tuberculosis, syphilis, rheumatism, etc.). Treatment. Topically: 1 % hydrocortisone suspension; 0.3 % prednisolone solution; 0.1 % dexamethasone – 3-4 times a day. Eye films containing dexamethasone (1-2 times a day). Subconjunctival injections of 0.3% dexamethasone solution; 0.4% dexamethasone solution 2-3 times a week. This is added to a 2% solution of amidopyrine with 0.1% solution of adrenaline hydrochloride – 4-5 times a day. Electrophoresis with 0.1% hydrocortisone solution, 2% calcium chloride solution, with 1% dimedrol solution daily, a course of 15-20 treatments gives good results. Locally – heat. At the stage of resorption, 0.1 % lidase solution is injected. General treatment: anti-allergic, anti-inflammatory therapy, specific therapy in chronic infection.
Intraocular pressure (IOP) is the pressure exerted by the contents of the eyeball on the walls of the eye. The value of IOP depends on the stiffness (elasticity) of the membranes, the amount of aqueous humor, and on the blood supply to the intraocular vessels. IOP (ophthalmotonus) is maximal in the early morning hours, decreases in the evening, and reaches its minimum at night. The relative constancy of IOP values in healthy individuals is caused by the correct correlation between the production and outflow of the intraocular fluid.
Normal limits of IOP measured with the Maklakov tonometer (10 g) in healthy people are 16-25 mm Hg. IOP is usually the same in both eyes, sometimes there may be a difference of 1-2 mmHg. In infants and young children, IOP is measured under anesthesia. IOP is subject to daily fluctuations within ± 4 mmHg, usually higher in the morning and at 11-12 h, and declines slightly after 4 p.m.
GLAUCOMA is a group of eye diseases with constant or periodic elevation of IOP followed by development of visual field defects, optic atrophy and reduction of central vision. There are 1 million 25 thousand glaucoma patients in Russia. 30% of visually impaired people have lost their vision due to glaucoma. There are three main types of glaucoma: congenital, primary and secondary.
CONGENITAL GLAUCOMA
Congenital glaucoma is a consequence of the incorrect development of the eye drainage system, infectious diseases of the mother during pregnancy, exposure of the pregnant woman during X-rays, avitaminosis, endocrine disorders, and alcohol abuse. Hereditary factors also play a role in congenital glaucoma.
In 90% of cases, this pathology is diagnosed in the maternity home, but it may manifest itself later – at the age of 3-10 years (infantile congenital glaucoma) and at the age of 11-35 years (juvenile congenital glaucoma).
The treatment for congenital glaucoma is surgical and immediate.
Surgery should be performed as early as possible, in fact as soon as the diagnosis is made.
PRIMARY GLAUCOMA
Primary glaucoma is one of the most frequent causes of irreversible blindness.
Primary glaucoma is classified according to the form and stage of the disease (stage of development of the pathological process), the degree of IOP compensation, and the dynamics of visual function.
The forms of glaucoma. The form of glaucoma depends on the structure of the anterior chamber angle. The angle of the anterior chamber is determined by gonioscopy – examination of the angle of the anterior chamber with a lens called a gonioscope, and a slit lamp.
Depending on the structure of the anterior chamber angle, primary glaucoma is subdivided into open-angle and closed-angle.
The clinical picture of open angle glaucoma. In most cases, open angle glaucoma develops without the patient noticing it, and he consults a doctor when his vision is already reduced. Sometimes patients complain of a feeling of fullness in the eye, recurrent pain in the eye, headache, pain in the area of the eyebrow, and flickering before the eyes. Some of the earliest signs to suspect glaucoma are increased eye fatigue when working at close distances and the need for frequent changes of glasses.
On examination, trophic changes in the iris are seen: segmentary atrophy of the iris, disruption of the integrity of the pigmentary border around the pupil, pseudoexfoliation – grayish-white scales – sprayed around the pupil and on the front capsule of the lens. Several years after the onset of the disease, optic atrophy develops.
An acute attack of glaucoma may occur under the influence of emotional factors, when staying in the dark for a long time, or when the pupil is dilated with medications. In an acute glaucoma attack, patients complain of severe breaking pain in the eye, but more around the eye, along the branching of the trigeminal nerve (temple, forehead, jaw, teeth), headache, blurred vision, iridescent circles when looking at a light source. Examination reveals congestive injection of the eyeball vessels, cornea is edematous, pupil is dilated, IOP is elevated to 50-60 mm Hg.
Treatment of an acute glaucoma attack. Timely diagnosis and adequate treatment of an acute glaucoma attack largely predetermine the prognosis since the optic nerve fibers die during the attack. Treatment of patients with an acute glaucoma attack should be performed in an eye hospital. Treatment should be started as soon as the diagnosis is established.
A 1% solution of pilocarpine hydrochloride is injected every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every hour for the next 2 hours and then every 3 hours. At the same time, instillation of 0.5% solution of timolol maleate 2 times and giving a tablet of acetazolamide (diacarb) are administered. After 3 hours, if the attack is not subdued, a lytic mixture of 1 ml of 2.5% chlorpromazine solution (aminazine), 1 ml of 2.5% promethazine solution (pepolfen) or 1 ml of 1% diphenhydramine solution (dimedrol) and 1 ml of 2% trimeperidine solution (promedol) shall be given intramuscularly. Glycerin at the rate of 1.3 ml/kg in fruit juice is given intravenously. If the seizure does not resolve within 6 hours, the lytic mixture may be repeated. Distraction therapy (2-3 leeches on the temple, mustard powder on the back of the head, hot foot baths, 25 g of saline laxatives) shall be carried out. If the patient simultaneously has a hypertensive crisis, osmotic diuretics, hot foot baths and laxatives are contraindicated. The patient is referred to a hospital. If the attack is not relieved within 24 hours, an operation is performed: iridectomy.
Clinical picture of closed angle glaucoma. With closed angle glaucoma patients complain of shooting pains in the eye with irradiation into the corresponding part of the head, and feeling of heaviness in the eye. This form of glaucoma is characterized by recurrent blurred vision, more often in the morning, just after waking up, and iridescent circles when looking at a light source.
Sometimes closed angle glaucoma begins with an acute or subacute attack.
AGING CATARACTS, TYPES OF TREATMENT
Aging cataracts develop between the ages of 50-60 and older in both eyes, mostly not at the same time.
There are 4 stages in the development of senile cataracts: primary, immature, mature, and over-mature.
In the initial stage of cataract, some people may not complain about anything, while others notice that they see “flies” before their eyes and notice that their vision has become worse when they look at distant objects. In some people the initial cataract lasts for decades, in others the stage of immature cataract occurs after 2-3 years.Patients complain of a sharp decrease in vision. The crystalline lens turns gray-white with a pearlescent hue. Object vision is preserved.
In a mature cataract, the subject vision disappears, and only light perception with correct light projection is determined.
In over-mature cataract, the crystalline lens nucleus completely dissolves, only the capsule remains, and the patient is able to see again. However, the resorption of the crystalline lens by itself is extremely rare, and is preceded by years of blindness and severe complications (phacolytic glaucoma, phacolytic iridocyclitis).
Treatment of age-related cataracts. In the initial stage conservative therapy is advisable. It is used:
– agents that improve metabolic processes in the lens: cytochrome C + sodium succinate + adenosine + nicotinamide (oftan katahrom), azapentacene (quinax), vitafacol, vitayodurole in drops 2-3 times a day.
However, the main method of cataract treatment remains surgical – removal of the cloudy lens (cataract extraction). Currently, the indication for surgery is not its maturity, but the degree of vision loss. There are 2 basic methods of removing a cloudy lens: intracapsular extraction (the lens is removed together with its capsule) and extracapsular extraction (the anterior capsule, nucleus, and crystalline lens masses are removed, and the clear posterior capsule is left). Currently, ultrasound phacoemulsification through a tunnel self-sealing incision has become the most sparing and effective cataract extraction method.
The condition of the eye without a lens is called aphakia. The prescription of spectacles for distal vision is made 3 to 4 weeks after the operation (from +9.0 D to +12.0 D). Contact correction is possible.
Currently, aphakia correction is performed mostly with an artificial lens (intraocular lens – IOL) that is implanted immediately after removal of the cloudy crystalline lens during the surgery. The condition of the eye with an IOL is called artifactia.
Aphakia is a condition of the eye without a lens:
A) congenital primary (the lens plate does not detach from the outer ectoderm during embryogenesis) and secondary (the forming lens spontaneously resorbs)
B) acquired – occurs with spontaneous resorption and after cataract extraction
Signs of aphakia:
1) deep anterior chamber of the eye
2) Iris trembling (iridodonesis) during biomicroscopy due to loss of support
Methods of correction:
A) Eyeglass correction with collecting lenses +10.0-12.0 dpts (+3.0 dpts for reading) for the emmetropic eye. Has a number of disadvantages: limitation of the field of vision; increase of the retinal image; unilateral aphakia cannot be used (because of the inequality of the image of the same object on two retinas – aniseikonia)
B) Contact correction – it is possible to achieve an increase in vision up to 1.0; limitations of use: residual aniseikonia; individual intolerance; allergy; possible development of infectious complications
B) Intraocular correction – the most optimal method of correction, a surgical operation in which an opaque or dislocated natural lens is replaced by an artificial lens of appropriate power, which is calculated using special tables or computer programs. Advantages: more physiological, does not narrow the field of vision, eliminates the dependence of patients on glasses, does not distort objects, and forms an image of normal size on the retina.
