How to treat restricted eye movement. Visual and oculomotor disorders. Paralysis of individual eye muscles

18.11.2008, 21:04

Hello uv. doctor. Help me solve the problem. I am 36 years old. The problem appeared a long time ago, or rather, I saw the first symptoms at the age of 23 in the photo. One eye looked in the right direction, the other moved away as if towards the ear. At the age of 35, I noticed this appeared again and no longer in the photo, but I can see it every morning in the mirror, plus in the photo, when I concentrate my gaze on something. And the second eye twitches.
There were no constant dizziness before and after the operation. She underwent cholecystotomy 7 months ago. And the problem with my eyes began after two funerals of my parents.
I had an MRI yesterday, everything is normal except: in the area of the pons with lateralization to the region of the right middle cerebellar peduncle, a focus of increased intensity is visualized on T2-WI and FLAIR, and a hypointense n on T1-WI, without clear contours, measuring 11.5\8.5 mm . The phenomenon of perifocal edema and mass effect is not observed.
Conclusion: given the presence of one infratentorial focus, the presence of vascular pathology (focus of ischemia?), a focus of demyelination cannot be excluded.
It is recommended to undergo contrast enhancement.
What kind of diagnosis is this? Is this serious? Is it treated, or should I buy dark glasses over time? I worry all the time.

18.11.2008, 22:14

Dear patient, there are probably no serious concerns here, since the length of the disease is very significant, and if there was a threat to life or disability, it would have been realized long ago. However, given the presence of the outbreak and its localization, I think that it’s all about it. Therefore, I recommend this: MR or even better, MSCT angiography of intracranial arteries. It is necessary to exclude a vascular aneurysm that could cause such changes. Demyelination in your case is practically excluded even based on your medical history.

18.11.2008, 22:18

You need to have an MRI with contrast. Show me the tomograms and then we can say how serious it is and what treatment it needs.

19.11.2008, 01:28

And while waiting for the MRI, I will have questions.
Are there any other complaints? Were there any difficulties, problems with coordination...? Was there diplopia/double vision/, especially when looking to the left, if the right eye is squinting. Is there a difference in pupil size? Has your visual acuity decreased? If I understand you correctly, then the strabismus was discovered by chance from a photo and did not recur for 13 years, or at least was not noticed by those around you? Ask your parents if they noticed strabismus in childhood?
I just wish there were more clinics. Thank you.

19.11.2008, 10:12

Thanks everyone for the answers. Yes, while waiting for the MRI, I'm starting to worry. About 7 months ago before the operation, I felt that I couldn’t stand on my feet, there was a tugging under my knees, everyone said it was anxiety, they gave me motherworts to drink, and it went away after a while. Then I had dizziness, too, everyone said don’t make things up. Then after the operation the dizziness was frequent, but it went away. Now the pain is taking place, I thought it was acute chondrosis, I called a massage therapist, it became easier. Well, I did an echoencephalography, the answer did not reveal anything. I went to the ophthalmologist: 1.0-0.9, the vessels are uniform, D-z strabismus. I did a rheoncelographic study. Answer: in the basin of the internal carotid artery on the left: blood filling is increased by 24%, slight hypervolemia, the tone of large and medium arteries is increased, the tone of small arteries and arterioles is normal, the tone of venules is normal. Venous outflow is impaired. Right: blood supply is normal, the tone of large and medium arteries is normal, the tone of small arteries is normal, the tone of venules is normal. Left-sided asymmetry of blood supply. In the basin of the vertebral artery. Left: blood supply is normal, the tone of large and medium arteries is increased, the tone of small arteries is normal, the tone of venules is normal. Right: blood filling is increased by 22%, mild hypervolemia, the tone of large and medium arteries is normal, the tone of small arteries and arterioles is normal, the tone of venules is normal. Right-sided asymmetry of blood supply. Then another examination: background EEG with moderate diffuse changes in the form of suppression of the alpha rhythm, predominance of slow-wave activity (decreased functional activity of cortical neurons). When testing with eye opening, the activation reaction is weakly expressed. The pattern did not change during hyperventilation. Signs of gross local pathology and epileptiform activity were not identified. With photostimulation, a weakened reaction of rhythm assimilation is observed (low lability and excitability of neurons in the cerebral cortex due to the increased influence on them of nonspecific nuclei of the thalamus, nuclei of the inferior pons and medulla oblongata.
Nothing like this was observed in childhood. And in general, I didn’t know what a hospital was until I was 23. Then I suffered from stomach problems. I thought it was poisoning, I drank a capsule of chloramphenicol and choked on it. It stuck, and I seemed to be warped from fright, my limbs were closed and my mouth was twisted, my husband at that moment induced vomiting, while the ambulance arrived, I moved away a little. Later, doctors said that the levomycetin produced by the Belarusian plant was bad, the capsules stuck. But the impressions were enormous.
Then I constantly treated either the stomach or the gall bladder, and all my sorrows were associated with it. Then I didn’t get my period 2005-2006. Doctors shrug their shoulders. I already asked the doctor who removed the gallstone to look at everything below, his conclusion - the uterus and appendages were examined - without any peculiarities. I don't know what is happening and what will happen next.
This is life-threatening now, because I don’t understand (ischemic focus?).

19.11.2008, 16:15

If I understand you correctly, then the strabismus was discovered by chance in the photo, it does not cause double vision and it only bothers you as an aesthetic defect? Which eye is squinting? Try to answer all my previous questions, please.
Was it the neurologist who prescribed all the examinations for you? Do you have it examined?
It is impossible to assume the seriousness of the problem without a clear clinical picture and without MRI contrast.

19.11.2008, 20:30

Do you think that a beautiful woman doesn’t care about this? My eyesight is good, but the sight in the morning is scary. Previously, it was noticed only in the photo, I didn’t attach any importance to it, and when it was noticed, I immediately went to a neurologist, he did all these examinations and ordered an MRI, but we have an appointment for him for a year in advance, because it is free for residents of the city, so I got through an acquaintance after 5 months because the MRI did not work, but this Philips smoked))))) Again with contrast on November 27.

When any of the external muscles of the eyes is paralyzed, a special clinical picture develops with its own special symptoms. Although there are quite a few such paintings, they all have a number of common features.

These signs are as follows: 1) loss of appropriate eye movement, 2) strabismus, 3) secondary deviation of the healthy eye, 4) diplopia, 5) disorder of perception of spatial relationships (“false projection”), 6) dizziness and 7) change in head position.

Let's take a closer look at each of these symptoms.

1. Loss of one or another eye movement due to paralysis of any muscle is the simplest and most understandable symptom. For example, the external rectus muscle of the eye - m. rectus externus, - as is known, turns the eye outward. If, depending on the damage to the abducens nerve, it turns out to be paralyzed, then the patient will not be able to perform the test that I spoke about, that is, turn the eyes to the side. Imagine that we are dealing with paralysis of the right abducens nerve. The patient will fulfill your request to turn his eyes to the left well, since the corresponding mechanism is all in order. But when you ask to turn your eyes to the right, the left eye will perform this movement, but the right eye will not: the m rectus externus will not operate in it.

You will observe similar phenomena with paralysis of any muscle; only the direction in which the affected eye will not be able to move will change.

2. Strabismus, strabismus - this is essentially a passive contracture already known to you - only not on a limb, but on the eye. You remember that when a muscle is paralyzed, its antagonists bring the limb into a special forced position called contracture.

This law, common to most voluntary muscles, is also true for the eye muscles.

If, for example, abducens nerve paralysis is observed, and therefore m. recti externi, then the antagonist of the last muscle, m. rectus

interims, pulls the eyeball inward and firmly fixes it in this position. This position of the eye is called strabismus.

Since the eye will be close to the midline, this type of strabismus is called convergent (strabismus convergens).

On the contrary, if m. is paralyzed. rectus interims, its antagonist will pull the eye outward and fix it in this position. This type of strabismus is called divergent (strabisnms divergens).

3. Secondary deviation of a healthy eye will become clear to you if you remember that the movements of the eyeballs are associated and occur predominantly in one direction. If we voluntarily deviate the right eye to the right, then the left eye deviates in the same direction, i.e. to the right. This means what strength of impulse m receives. rectus extermis dexter, m. receives the same. rectus interims sinister. And the greater the impulse for the first muscle, the greater it is for the second.

Now imagine that you have right abducens palsy. The right eye, under the influence of a healthy antagonist, will move inward, i.e., it will take the position of converging strabismus.

As for the healthy left eye, at first glance it should not suffer any changes in the installation, since everything is fine in it. However, the clinic will show you that this is not the case: with paralysis of the right abducens nerve, the obviously healthy left eye will deviate inwards almost the same way as the diseased right eye.

Convergent strabismus will occur on both sides, while one eye is paralyzed.

How to explain this phenomenon, strange at first glance? When, from the moment of paralysis of the right abducens nerve, the right eye moves inward, the patient will constantly innervate the diseased muscle in order to put the eye in a normal position.

But, as I already told you, under this condition n m will receive amplified pulses. rectus internus sinister. And from this, the left eye will be brought to the midline, that is, it will also become in the position of converging strabismus.

Thus, unilateral abducens nerve palsy will produce bilateral strabismus.

Now imagine paralysis of m. recti interni dextri. Under the influence of the antagonist, the right eye will move outward and assume the position of divergent strabismus. To bring the eye to its normal position, the patient will intensively innervate the paralyzed muscle. From this, the same amplified impulses will be sent to m. rectus externus sinister, since both of these muscles act cooperatively. But under this last condition, the left eye will be pulled outward, that is, it will also become in a position of divergent strabismus.

Thus, paralysis of one part of the recti interni gives bilateral divergent strabismus.

It is necessary to clearly understand that, despite the apparent similarity of the phenomena in both eyes, their nature is deeply different: in one eye the deviation is of paralytic origin, in the other, so to speak, spastic.

4. Diplopia, or double vision, is a condition when a patient, looking at one object, sees it twice. To understand its origin, you must remember the physiology of visual acts.

When we look at an object, each eye perceives it separately, but we still see one object, and not two. Somewhere in the cortex there is a process of merging two perceptions into one. We do not know the mechanism of this fusion, but we know one of the conditions necessary for this: parallelism of the visual axes. As long as the installation of the eyeballs is such that the visual axes are parallel, we see one object with both eyes; but as soon as this parallelism disappears, the fusion immediately disappears, and a person begins to see with each eye separately, i.e. doubly. With paralysis of the eye muscles, strabismus occurs, as you already know, i.e. deviation of the eyes from their normal alignment. In this case, the parallelism of the ocular axes is naturally disrupted, i.e., the main condition for the development of diplopia is provided.

It is necessary, however, to make a reservation that diplopia is not always accompanied by strabismus and loss of eyeball movements, noticeable during a normal test. Very often, during examination, the eyes perform all movements, and strabismus is not visible, but the patient still complains of diplopia. This means that the paresis of some muscle is very insignificant and is only enough to cause a slight violation of the parallelism of the visual axes. To find out which muscle has paresis, they use a special research method using colored glasses. This method, the technique of which should be known to you from the course of eye diseases, easily solves the problem if it is a matter of paresis of any one muscle. With combined paralysis of several muscles, the task becomes difficult or even completely impossible to solve.

5. The correct assessment of spatial relationships depends, among other things, on the state of the muscular apparatus of the eye. No matter how psychologists look at this issue, for us doctors there can be no doubt that the degree of effort that the eye muscles make in determining the distance plays a large role.

When a muscle is paralyzed, the patient makes unusually great efforts to put the eye in its normal position. This excessive innervation corresponds to an incorrect assessment of the distance between objects and their relative position - the so-called “false projection”. As a result of this, the patient, wanting, for example, to take a knife, fork, etc. from the table, constantly “misses” and reaches out his hand in the wrong place.

6. Doubling of objects and “false projection” cause dizziness in patients. We do not know how these phenomena follow from one another, what their internal mechanism is, but the very fact of this connection is beyond doubt. Patients themselves often notice it and fight the painful feeling of dizziness in such a way that they close or bandage the sore eye with a scarf. This protective technique results in monocular vision, in which there can no longer be either diplopia or false projection. And then the dizziness stops.

7. Blindfolding is a conscious protective technique by which the patient is saved from the consequences of paralysis of the eye muscles. There are other techniques, also, in essence, of a protective nature, but not entirely consciously invented. These are various peculiar postures that the head takes in such patients.

For example, with palsy of the right abducens nerve, the right eye cannot turn outward. The patient has difficulty seeing objects located to his right. To correct this defect, he turns his entire head to the right and, as it were, exposes the sore eye to visual impressions coming from the right side,

This defensive technique becomes permanent, with the result that a subject with abducens nerve palsy can be identified by the manner in which they hold their head in the direction of the paralysis.

With paralysis of m. recti interni dextri the right eye cannot move to the left, and the patient turns his entire head to the left in order to expose the diseased eye to the corresponding impressions. Hence the manner of holding the head turned to the side, i.e. essentially the same as in the previous case.

Due to the same mechanisms, patients with paralysis of m. recti superioris slightly tilt their head back, and with paralysis of the m. recti inferioris lower it downwards.

These are the common symptoms of paralysis of the external eye muscles. Knowing them, as well as the anatomy and physiology of each muscle separately, it is possible to theoretically construct a specific clinical picture of paralysis of each muscle separately, and these theoretical constructions, generally speaking, are justified in practice.

Among the particulars, paralysis of m. deserves special mention. levatoris palpebrae superioris - so-called ptosis. This is the result of damage to the oculomotor nerve; ptosis is expressed in the fact that the patient's upper eyelid remains drooping, and he cannot lift it, cannot open his eyes.

In addition to paralysis of individual muscles, there is another type of paralysis in this area - the so-called associated paralysis, or gaze paralysis. They are horizontal and vertical.

With horizontal gaze palsy, the patient's eyes are positioned as if he were looking straight ahead, and there is no strabismus. But he has no lateral movement: both eyes cannot cross the midline. Interestingly, convergence can sometimes persist.

This disorder is usually observed with lesions in the pons; Apparently it is associated with damage to the posterior longitudinal fasciculus (fasciculus longitudinalis posterior).

With vertical gaze palsy, lateral eye movements are not impaired, but there is no upward or downward movement, or, finally, both upward and downward.

This symptom is usually observed with lesions in the quadrigeminal region.

Another type of oculomotor disorder, somewhat similar to the previous one, is concomitant eye deviation. It is observed most often in the first time after a cerebral stroke. As a rule, it is combined with the same deviation of the head. The disorder consists in the fact that the patient's head is turned to the side, for example to the left, and the eyes are also directed to the left. When asked to turn the eyes to the right, the patient performs this movement to a small extent and for a short time, after which they return to their previous position.

This symptom is observed with lesions in different parts of the brain. The eyes are usually squinted towards the hearth, less often in the opposite direction (ancient formulas: “the patient looks at his hearth,” “the patient turns away from his hearth”).

Another disorder of the oculomotor system, already with the character of hyperkinesis, is observed - nystagmus.

This name refers to rhythmic twitching of the eyeballs, most often occurring with extreme abduction of the eyes, less often during rest.

If nystagmus occurs with lateral positions of the eyes, then they speak of horizontal nystagmus; if when the eyes move up or down, then this is called vertical nystagmus. There is also rotatory nystagmus - eye twitching of a rotational nature.

The mechanism of nystagmus, despite the frequency of this symptom, still remains unclear; Apparently in different cases it is heterogeneous.

With this we can put an end to the pathology of the external muscles of the eye and move on to the internal muscles, i.e. the pupillary muscles.

The pupil is not subject to human will - its movements occur as a reflex. Therefore, the pathology of the pupil is the pathology of those of its reflexes, which I have already told you about.

Such damage can occur, for example, with a stroke (cerebral hemorrhage) or with congenital brain lesions. If one of the three extraocular muscles is affected, the affected eye deviates in the opposite direction, this is the angle of primary deviation. The amount of eye deviation (squint angle) increases as the gaze moves towards the action of the affected muscle.

If the patient looks at an object with the diseased eye, then the healthy eye deviates (this is the angle of secondary deviation), and at a much larger angle than the one to which the diseased eye was deviated. The eye does not move towards the affected muscle. With fresh lesions, when the body has not yet had time to adapt to new conditions, such patients experience double vision and dizziness, which disappear if one eye is closed. Paralytic strabismus is also characterized by a forced position of the head - a slight turn or tilt. If all three nerves innervating the external eye muscles are affected, the eye becomes completely motionless.

Treatment of strabismus caused by damage to the oculomotor nerves

Before treatment, the exact cause of strabismus must be determined and the underlying disease treated. Be sure to prescribe exercises to develop eye mobility, then add physiotherapeutic procedures to stimulate the work of these muscles.

To eliminate double vision in gases, use special glasses and turn off or incompletely turn off the function of the affected eye using an opaque spectacle glass.

In case of persistent paralysis, a surgical operation is performed, which is carried out no earlier than six months after the treatment.

Friendly strabismus

A disorder of the binocular vision mechanism can be congenital or acquired (for example, with a sharp decrease in visual acuity in one eye). It can be independent or occur against the background of some other disease, be either periodic or constant. There is also strabismus, in which one particular eye squints or both alternately.

Convergent strabismus is a strabismus when the visual axis of one of the eyes is deviated inward, divergent - when the visual axis is deviated outward.

Concomitant convergent strabismus usually develops in early childhood and is often intermittent at first. Gradually, a restructuring of the child’s entire visual system occurs, the result of which is the gradual exclusion of part of the image from visual perception and an adaptive loss of part of the visual field occurs, with the help of which the body eliminates double vision. This prolapse is eliminated by closing one eye. With age (if left untreated), strabismus becomes severe and permanent.

Treatment of concomitant strabismus

First of all, such a patient undergoes correction of impaired visual acuity of the squinting eye. To do this, after removing accommodation (the work of the ciliary muscle that changes the curvature of the lens), glasses are prescribed by instilling an atropine solution. Permanent optical correction in combination with special eye exercises - the main method of treating convergent and divergent strabismus . When binocular vision is restored, optical correction is gradually reduced and then canceled.

Panina Valentina Viktorovna

Actress, Honored Artist of the RSFSR

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I found out about you on the Internet - I urgently need an MRI.

And after the performance I’m with you. I really liked your staff. Thank you for your attention, kindness and accuracy.

May everything be as good in your soul as I am now, despite all the problems...

Be!!! We're happy! Your Panina V.V.

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I found out about you on the Internet - I urgently need an MRI.

And after the performance I’m with you. I really liked your staff. Thank you for your attention, kindness and accuracy.

May everything be as good in your soul as I am now, despite all the problems...

Be!!! We're happy! Your Panina V.V.

I found out about you on the Internet - I urgently need an MRI.

And after the performance I’m with you. I really liked your staff. Thank you for your attention, kindness and accuracy.

May everything be as good in your soul as I am now, despite all the problems...

Be!!! We're happy! Your Panina V.V.

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Sergei Shnurov

Russian rock musician, film actor, TV presenter and artist.

Ts.M.R.T. "Petrogradsky" thank you!

Thank you very much for such good, professional service in your clinic. Nice, comfortable! Great people, great conditions.

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Rusanova

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Everything is very competent, very friendly service. I will recommend this clinic to my friends. Good luck!!!

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Kuznetsov V.A.

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Khrabrova V.E.

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Thank you very much for the consultation and examination... She was very polite, accessible and explained the process and result in detail.

Naturally, with age, the risk of various diseases increases. Eyes are no exception: age-related cataracts, retinal dystrophy... Only regular examination by an ophthalmologist allows you to identify serious eye diseases in the early stages and prevent possible loss of vision.

In some cases, for example, during an acute attack of glaucoma, the count is not in days, but in hours: the earlier treatment is started, the higher the chances of restoring vision. Knowing some of the signs of eye diseases will help you promptly seek help from a specialist.

Sudden deterioration of vision in one eye

If you are over 60 years old, and especially if you have myopia, arterial hypertension, diabetes mellitus, or systemic diseases, there is a risk that vision loss is caused by vascular disorders - occlusion of the central retinal artery or thrombosis of the central retinal vein.

In such cases, time is counted by the clock, and only timely specialized assistance will help restore vision, otherwise irreversible blindness of the affected eye occurs.

The sensation of a black curtain in front of the eyes that obscures part of the field of vision

Sensation of a black or translucent curtain in front of the eyes from the periphery. This symptom is often observed with retinal detachment. The condition requires immediate hospitalization. The earlier treatment is started, the greater the likelihood of vision restoration.

Sharp pain in the eye, redness, blurred vision, possibly nausea, vomiting

These may be signs of an acute attack of angle-closure glaucoma. Intraocular pressure rises sharply, which can damage the optic nerve. Immediate reduction of intraocular pressure is indicated - up to surgical treatment. Don't wait for the pain to go away. See your doctor immediately.

Gradual or sudden narrowing of the field of view

A gradual or sudden narrowing of the field of vision, ultimately leading to the ability to see only what is located directly in front of you - the so-called “tubular” vision. You may have glaucoma, one of the main symptoms of which is a narrowing of the field of vision as a result of damage to the optic nerve.

Without appropriate conservative or surgical treatment, vision will deteriorate. End-stage glaucoma is complete loss of vision. Severe pain may occur that continues even after surgery and ultimately requires removal of the eye.

Gradual deterioration of central vision, blurred, distorted images (straight lines appear wavy, curved)

These may be symptoms of macular degeneration - a dystrophic disease of the central region of the retina - the macula, which plays the most important role in providing vision. The incidence increases sharply with age.

Without supportive treatment, vision gradually deteriorates; glasses do not help. Currently, there are various treatment options that are used depending on the form of macular degeneration.

Also, a sudden decrease in vision may be caused by a macular hole in the retina, i.e. retinal tear in the central zone. It is necessary to immediately contact an ophthalmologist to clarify the diagnosis, since a retinal tear in the macular area, if treatment is not started in time, leads to irreversible loss of vision.

Fog before the eyes, decreased brightness and contrast

These symptoms may be caused by developing cataracts - clouding of the lens. Vision deteriorates gradually, eventually reducing to the ability to distinguish only light. In most cases, urgent medical care is not required; at a certain stage, planned surgical treatment is carried out - cataract removal with implantation of an artificial lens.

However, periodic observation by an ophthalmologist is recommended, since in some cases cataracts may be accompanied by increased intraocular pressure, which requires urgent surgical treatment. In addition, as cataracts develop, the lens becomes harder and larger in size, which can complicate the operation to remove it, so you need to visit a specialist regularly to determine the optimal time for surgical treatment.

Dark spots, floaters, fog or blurred vision

If you have diabetes, these may be signs of diabetic retinopathy - damage to the retina caused by diabetes. As diabetes progresses or becomes decompensated, the risk of eye complications increases dramatically.

It is necessary to regularly visit an ophthalmologist to examine the fundus, since changes in the blood vessels and the retina itself, hemorrhages in the retina and vitreous body can cause irreversible loss of vision.

The ophthalmologist will prescribe you the therapy necessary specifically for the eyes, which may not only involve taking certain medications, laser treatment is often required, and other treatment methods may also be used. Timely laser coagulation of the retina is the only way to preserve vision in diabetes mellitus.

A burning sensation, sand in the eyes, a sensation of a foreign body, lacrimation or, conversely, a feeling of dryness

Such complaints occur with dry eye syndrome, the frequency and severity of which increases with age. Usually we are talking primarily about discomfort and deterioration in quality of life, rather than about any danger to the eyes.

However, severe dry eye syndrome can cause some serious pathological conditions. Your ophthalmologist will tell you more about dry eye syndrome, conduct the necessary examination, and recommend which moisturizing drops are best for you to use.

Ghosting

Double vision when looking with one or both eyes can be caused by many reasons, both from the eyes and other organs: intoxication, vascular disorders, diseases of the nervous system, endocrine pathology. If double vision suddenly appears, immediately contact a therapist, ophthalmologist, neurologist and endocrinologist.

Floaters before the eyes

Usually floating spots, threads, “spiders” before the eyes are explained by destruction of the vitreous body. This is a harmless condition associated with age-related changes in the structure of the vitreous humor - the transparent gel-like content that fills the eyeball. With age, the vitreous body becomes less dense, liquefies, and is not as tightly adjacent to the retina as before; its fibers stick together, lose transparency, casting a shadow on the retina and are perceived as defects in our field of vision.

Such floating opacities are clearly visible on a white background: snow, a sheet of paper. The destruction of the vitreous body can be caused by: arterial hypertension, cervical osteochondrosis, diabetes mellitus, head injuries, eye and nose injuries, etc.

However, an unexpected spot in front of the eyes, a “curtain”, can be caused by a serious pathology that requires urgent treatment - for example, hemorrhages in the retina or vitreous body. If symptoms occur suddenly, on one day, immediately consult an ophthalmologist.

If you have any previously absent visual symptoms, it is better to immediately consult a specialist. If your vision has deteriorated sharply over several hours or days, or pain bothers you, do not waste time. Even if it is not possible to consult with your ophthalmologist, you can go to the emergency eye care office, which is available in every city in multidisciplinary hospitals or eye hospitals.

As a last resort, many opticians have experienced ophthalmologists who will conduct the minimum necessary examination and give recommendations for further action.