Rupture of the uvea treatment. Method of surgical treatment of traumatic ruptures of the choroid of the eyeball. Optic nerve damage

DISSOCIATION OF MICROBES, a process that causes partial or complete transformation of a pure bacterial culture of a normal type into one or more subtypes that differ from the original microbe in their morphological structure, according to appearance colonies, according to serological and biochemical. properties. The process of D. can proceed not only in the direction from primary culture to variational types, but also vice versa. D. occurs either spontaneously or under the influence of certain factors, such as: growing at unfavorable temperatures, using unsuitable nutrient media or fasting, physical. state of the environment (humidity, dryness, volume), oxygen pressure, antiseptic substances, foreign proteins, specific serums, microbial growth products (filtrates of homologous and even heterogeneous cultures), etc. At present. Currently, it is generally accepted to designate primary colonies with the letter S (English smooth-gentle, smooth), and secondary colonies with R (English rough-rough, rough). Between these two types there are a number of intermediate variational types of colonies; they are designated by the letter O. Character traits S colonies on solid media are as follows: small, round, convex, correct form, delicate, with a shiny surface; colonies R-irregular shape with pitted, fringed edges, wrinkled, rough, often glassy, ​​usually tightly fused with the environment [see. dept. table (vv. 55 - 56), fig. 2 and 3]; O colonies have a mucous mucoid structure. When growing in broth, S causes uniform turbidity, and R forms a flocculent sediment. In physiol. salt solution (0.8% NaCl) S gives a uniform suspension, and R forms flakes. The morphological differences of the microbes that form S, O and R colonies are as follows: type S consists of normal microorganisms; intermediate type O is characterized by the presence of long filaments, cocci-shaped forms and giant cocci; in type R, individuals are significantly shortened compared to S (Escherichia coli, typhus, dysentery, etc.), in motile bacterial species they are either completely devoid of mobility or have it only slightly weak degree, capsule ones do not have capsules. Microorganisms of R colonies are usually less active (decomposition of sugars, proteins, liquefaction of gelatin) and have reduced virulence and toxigenicity compared to type S (diphtheria, typhoid, dysentery); the exception is Escherichia coli and anthrax, in which R is more virulent than S. Type S, being a carrier of two or more antigens, is most suitable for immunization. Regarding sustainability in conservation characteristic features newly obtained variational types, then R possesses it to a greater extent than O, and more difficultly passes into the basic S. To achieve this, multiple passages through a normal animal organism are used. Secondary colonies are formed either in the center or along the edges of the main culture, and can be isolated in the form of papillae or merge into a homogeneous secondary culture. Primary colonies, having reached their highest development, undergo degenerative changes, become glassy, ​​and secondary daughter colonies appear on their surface. Dissociative processes also take place in liquid media, and occur more vigorously in them than in solid media. D. m. is observed in representatives of all bacterial groups, both aerobic and anaerobic, both pathogenic and saprophytic, among all morphol. species, perhaps with the exception of spirochetes. There is a certain kind of parallelism in the process of D. in different species, but how far it goes cannot yet be said. Currently, the view is increasingly taking root that the basis of D. microbes is the general biol. the law of variation and mutation, widespread among single-celled organisms, and since D. is stimulated by the presence of unfavorable factors and type R is more resistant than S, some scientists base this process on the principle of preserving the species. (See also Variability microbes.) Lit.: Gedley F., Dissociation of microbes and its relation to biochemical, immunological, serological reactions and virulence, Profil. medicine, 1928. appendix (lit.); Forerunner S., The problem of microbial variability V new lighting, Vesti, microbiol., epidemiol. and para-aitol., vol. VIII, c. 1, 1929; II a d 1 e y Ph., Microbic dissociation, Jouni. of infection, diseases, v. XL. No. 1, 1927 (lig.). Yu. Makarova-Tirasevpch.

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Damage to the choroid

Most frequent sight lesions of the choroid are its ruptures, which are always accompanied by hemorrhages (Fig. 1). As a rule, the detection of a rupture is preceded by the detection of hemorrhage into the choroid, since only after the blood has been reabsorbed, whitish or pink stripes of the choroidal rupture become visible. The resulting circulatory disorders in the choroid due to vascular damage ultimately lead to the development of atrophic changes.

Rice. 1. Rupture of the choroid

Iris contusions

Iris contusions can clinically manifest as tearing of the pupillary margin, mydriasis, iridodialysis, and aniridia.

With contusions, the pupil acquires an irregular, polygonal shape, often in the form of an elongated oval with tears in the pupillary edge and pigment deposition on the anterior capsule of the lens (Vossius ring). Miosis during contusion is rarely observed and is the result of a spasm of accommodation or vegetative dystonia.

Paresis or paralysis of the iris sphincter can cause paralytic mydriasis. In this case, there is deterioration in vision at close range, the reaction of the pupil to light is absent or remains sluggish. When the dilator is intact, it is necessary to use mydriatics with caution, since the pupil in such cases dilates to its maximum and remains dilated for a long time. An immobilized pupil against the background of a developed inflammatory reaction contributes to the formation of circular synechia, pupil occlusion, and disruption of the outflow of aqueous humor from the posterior to the anterior chamber, which leads to increased intraocular pressure and the development of secondary glaucoma.

At iridolysis- separation of the iris root from the ciliary body - the pupil takes on a D-shape (Fig. 2). The presence of a second hole (other than the pupil) can lead to diplopia, as well as photophobia as a result of excessive exposure to the internal parts of the eye. The edge of the lens is often visible through the tear area. When the iris is torn near the pupillary edge, the pupil becomes irregular shape. When dialysis exceeds 1/2 of the iris circumference, inversion occurs with pupil deformation and exposure of the anterior lens capsule (Fig. 3).

Rice. 2. Post-traumatic iridodialysis

Rice. 3. Post-traumatic iridodialysis and traumatic cataract

With severe contusions, complete separation of the iris from the root is possible - aniridia. Damage to the iris is usually accompanied by bleeding from the vessels into the anterior chamber, which is filled with blood partially or completely (partial or total hyphema). Damage and disruption of the permeability of the vessels of the iris can lead to repeated hemorrhage, which raises the threat of secondary glaucoma and hematocornea.

Treatment. Showing peace, bed rest, applying a binocular bandage with an elevated head position for 2-3 days. First, hemostatic agents are prescribed (ascorutin orally, dicinone parabulbarly, aminocaproic acid orally or intravenously, 10% calcium chloride solution intravenously, etamsylate orally or parabulbarly), and from the 4-5th day - resorption therapy (fibrinolysin, hemase parabulbarly), physiotherapy (phonophoresis papain). If there is no positive effect, on the 4th-6th day it is necessary to perform a paracentesis with lavage of the anterior chamber. Surgical removal of iridodialysis, mydriasis, and iris coloboma for optical purposes is performed after 2-3 months. after injury.

Choroidal rupture manifests itself in two types. The so-called indirect tear lies mostly near the nipple and appears as a narrow, yellowish-white, sometimes bordered with pigment, arc-shaped and concentric to the nipple strip. The retinal vessels pass over the gap evenly or with a slightly noticeable deflection. Fractures mostly form in singular, less often there are several of them. The cause of such indirect ruptures is most often some kind of force acting on the eye from the front (a blow from a stone, a ball, etc.). Direct ruptures mostly occur with gunshot wounds, if the bullet only touches the eye, or if the wound channel passes only close to eyeball. They are called straight because they lie where the force acted from outside on the eyeball. These ruptures have the appearance of very large, irregularly limited and widely gaping breaks, which are often accompanied by damage to the retina, so that the picture of chorioretinitis sclopetarium develops.

With uncomplicated ruptures of the choroid, visual impairment depends only on their position. Those located outside the maculae do not cause any visual impairment. In many cases, however, there are changes in the macula itself (traumatic macular disease) that reduce vision.

Since the uvea is richly supplied with vessels everywhere, its damage is accompanied by bleeding. Smooth ones bleed least cut wounds iris, especially in operating rooms, since although many vessels are cut, they are only small ones, and the trauma itself is minimal. Accidental injuries bleed much more, since the injury is more severe and the vessels are torn rather than cut. Bleeding is especially severe during iridialysis, probably because the circulus arteriosus iridis major is damaged. When the iris is damaged, blood flows into the anterior chamber. A blood clot will soon form; Therefore, with fresh injuries, clots lying in the anterior chamber or on the iris are visible, and often the very site of the injury is covered with such a clot. In the coming days, the clots liquefy, apparently due to the breakdown of fibrin, and red blood cells are released and settle to the bottom of the chamber. Now the typical h urh aem a is just formed, i.e., an accumulation of blood cells at the bottom of the chamber, limited from above by a strictly horizontal line and when the head is tilted, it always flows into the lowest point. this moment place. When the choroid ruptures, blood flows under the retina; then a picture of either subretinal extravasation or more severe hemorrhage of blood retinal detachment appears. With very severe contusions, large hemorrhages inside the eye can occur, some in vitreous, partly into the perichoroidal space. In such cases, the perception of light completely disappears, but sometimes it is restored later when the blood resolves. This is the only exception to the rule that turbidity of media never destroys light perception.

After internal bleeding A ruby-red coloration of the vitreous body and chamber humor may develop. Vitreous staining is visible only in exceptional cases, under particularly favorable conditions. Coloration of chamber moisture occurs amazingly quickly, often within a few hours; Chamber moisture then appears as a transparent but intensely red liquid. All details of the iris pattern are clearly visible, but as if through red glass. Obviously, this phenomenon depends on the dissolution of hemoglobin in the chamber moisture. To a lesser extent, such dissolution is also observed with hyphema; layer of blood borders with colored green color iris or this staining is detected after the hyphema has resolved. The coloration is especially noticeable on the bluish-gray iris. Sometimes it seems completely grassy green.

The tissue of the uveal tract is in a state of certain tension during life: therefore, violations of the integrity of the iris - ruptures - gape very much; ruptures of the choroid gape little. With aseptic healing of these injuries, however, no scar tissue is formed at all. These holes and folds therefore do not heal, but remain as such for life. Damage caused by bruises is especially suitable for confirming this fact, since here the cavity of the eyeball does not open and any external irritation that could lead to inflammation disappears. And the iris stump remaining after iridectomy behaves the same way: years later, its tissue is still trimmed smoothly, as it was immediately after the operation.

The prognosis of these concussion injuries at the beginning, while it is still impossible to clearly take into account all the harm they caused, must be made carefully. But since in the absence of a perforating wound there is nothing to fear, subsequent inflammation, then, at least, there is no reason to expect further deterioration. On the contrary, as the hemorrhages are absorbed, vision often improves significantly. In any case, the disfigurement resulting from damage to the iris remains forever, and one has to put up with it.

Blunt injuries (or concussions) constitute 43 % Among all injuries to the eye, they are often observed in everyday life (domestic trauma) and belong to the category of severe injuries, since contusions damage to one degree or another all the membranes of the eye (sclera, choroid), retina, optic nerve, lens.

In terms of severity, contusion injuries of the eyeball take second place after perforated wounds. Contusions of the organ of vision in their own way clinical picture are very diverse - from minor hemorrhages under the conjunctiva of the eyelids to crushing of the eyeball and surrounding tissues. They can occur as a result of blunt impact of a damaging factor directly on the eye and its appendages (direct contusions) or indirectly (when affecting more or less distant parts of the body). The source of injury in the first case is bruises with a fist or any object, falls on stones, on various protruding objects, an air wave, a jet of liquid, etc. Indirect contusions are the result of blows to the head, compression of the body, etc.

Patients may experience pain nausea, possible vomiting andrare pulse. They noticedeterioration or loss of vision, immediately detected upon examinationhemorrhages under the skin of the eyelids and mucous membrane,paralytic dilatation of the pupil, tears of the pupillary edge, tears of the iris at its root,

In recent years there has been the new kind eye injuries due to contusions: ruptures of the eye along notches on the cornea. For many years, surgery was performed to correct myopia using incisions in the cornea. Thin scars formed in the area of ​​the incisions, which led to a change in the curvature of the cornea. With blunt trauma to the eye, sometimes the cornea ruptures along the scars, which leads to serious consequences - loss of the membranes of the eye and hemorrhages.

The post-concussion period is usually complicated by iritis and iridocyclitis.

Classification

Currently in the Russian Federation there is no generally accepted classification of mechanical eye injury in general and closed injury eyes in particular, which makes it difficult to formulate uniform approaches to providing medical care victims with a closed eye injury.

Classification B.L. Polyaka (1957) distinguishes between contusion without scleral rupture and with scleral rupture.

The classification of G. A. Petropavlovskaya (1975) has become widespread, where contusion is classified according to severity.

• I degree – contusions that do not cause decreased vision during recovery. They are characterized by temporary reversible changes (swelling and erosion of the cornea, Berlin opacification of the retina, Vossius ring, spasm of accommodation, etc.).
• II degree – contusions causing persistent vision loss (deep corneal erosions, local contusion cataracts, pupillary sphincter ruptures, retrolental hemorrhages, etc.).
• III degree – contusions, which are characterized by extremely severe changes, entailing, on the one hand, the possibility of volumetric enlargement of the eye due to subconjunctival rupture of the sclera, and on the other, a state of sharp hydrodynamic shifts. Three groups can be distinguished here:
  • subconjunctival scleral tears;
  • persistent ocular hypertension;
  • persistent deep hypotension.

Currently widely used in the Russian Federation classification contusions of the organ of vision (which are one of the options for TTG) by severity (Volkov V.V., Danilichev V.F., Eryukhin I.A., Shilyaev V.G., Shishkin M.M.)

Severity	Clinical manifestations	Prognosis for vision and duration of treatment
	foreign bodies on the conjunctiva or in the superficial layers of the cornea. subconjunctival hemorrhages (hyposphagmas), peripheral corneal erosions,	Favorable (full recovery). Almost everyone returns to work within 2 weeks
	Non-perforating wounds of the eyeball, swelling, continuous tear in the superficial and deep layers corneas, extensive hyphema, paresis of intraocular muscles, tear of the pupillary edge of the iris, limited Berlin opacification of the retina in the periphery	Relatively favorable (minor damage) Most of the victims return to work. Inpatient treatment 4-8 weeks
	Imbibition of the cornea with blood, total hyphema, extensive rupture or detachment of the iris, opacification, subluxation or dislocation of the lens, or aphakia, partial or total hemophthalmos, rupture or detachment of the choroid or retina, Berlin opacities central department fundus	Doubtful (significant damage) A small number of victims return to work. Treatment for more than 2 months
Extremely severe	Avulsion (rupture, compression in the bone canal) optic nerve.	Unfavorable due to total and irreversible loss visual functions. Inpatient treatment for many months. Visual disability

At the core international classification mechanical eye injury, proposed in 1996 by Kuhn F. et al, lies not in the mechanism of injury (wound or contusion), but in the pathomorphological result - the integrity of the fibrous capsule. The criterion for a closed eye injury is the absence of damage to the entire thickness of the fibrous capsule of the eye.

According to international classification There are 4 types of TTG, designated by capital letters of the Latin alphabet (A, B, C, D).

• In case of TTG type A (contusion), the integrity of the fibrous capsule is not broken, changes in intraocular structures caused by the influence of a damaging factor are diagnosed.
• In case of TTG type B (non-perforated wound), there is a non-through damage to the fibrous capsule without the presence of foreign bodies in it. Such injuries include abrasions, erosions, scratches, lamellar non-perforated dissections of the cornea and sclera.
• Type C TTG (non-perforated wound with superficial foreign bodies) includes cases of non-through damage to the fibrous capsule with the presence of foreign bodies in it that caused this damage.
• TTG type D (mixed cases) includes mixed conditions in which damage to both the contents and the wall of the eye (without its perforation) is combined.

According to the severity of visual impairment

• 1st degree visus > 0.5
• 2nd degree visus 0.4 – 0.2
• 3rd degree visus 0.1 – 0.02
• 4th degree visus< 0,02 – 1/¥ pr.l.certa
• 5th degree visus Vis = 0- 1/¥ pr.l.incerta

In the international classification, an important criterion is afferent reaction of the pupil, by which the presence or absence is assessed afferent pupillary defect (AZD). The pupil of an eye with an afferent deficiency paradoxically dilates with light because the pupil dilation caused by light being diverted from the healthy eye outweighs the constriction caused by stimulation of the impaired eye. Thus, there can be a positive or negative AD. It should be noted that a decrease in visual acuity by more than 50% and a positive AD usually indicate severe eye injury.

Diagnosis of closed eye injury

Visometry

Visual acuity testing is a very important diagnostic method for closed eye injury, as it determines such a classification parameter as the severity of the injury.

• Visual acuity is checked using an optotype projector, a tabular method using Golovin-Sivtsev tables and analogues or ETDRS tables.
• When visual acuity is less than 0.1, a study of the entoptic phenomenon of autoophthalmoscopy (AOS) is indicated, which is easily performed transpalpebrally using a portable flashlight. A positive AOS phenomenon indicates a retinal visual acuity of at least 0.1.
• If visual acuity is less than 0.01, the following levels of visual function must be checked:
  • Counting fingers on the face
  • Movement of the hand near the face
  • Prim-Rose test (determining the direction of the red stripe when the eye is illuminated using Meddox glass); a positive test indicates the functional integrity of the macular area,
  • Light projection,
  • Light perception. For maximum information content, it is advisable to determine light perception in a dark room using the brightest light sources (for example, a head-mounted ophthalmoscope).

Perimetry

• To study the visual field, any available hardware methods can be used: static, kinetic, threshold perimetry, campimetry, microperimetry, etc.
• If the patient, due to low vision, does not see the fixation point, then it is possible to fix the gaze on his own finger, placed on the fixation point,
• If the patient, due to low vision, does not see the perimetric test object, then the field of vision is examined using the control method, when the victim looks at the face of the doctor sitting opposite him and determines with lateral vision the movement of the fingers of the doctor’s hand, which is abducted along the four main meridians. The doctor compares the patient’s field of vision with his own,
• In all cases of absence of a visual field, a study of the entoptic phenomenon of mechanophosphene (MP) is indicated. The doctor presses the glass rod through the closed eyelids onto the patient's eye in the four oblique meridians with the patient's eye being maximally abducted in the contralateral direction. The patient identifies circles of light in the direction of his gaze. Positive symptom MF indicates the functional integrity of the retina in this quadrant and its normal anatomical position.

Tonometry

To determine IOP in cases of closed eye injury, it is possible to use non-contact tonometry methods. Tonometry according to Maklakov allows you to more accurately determine the level of IOP, but is a contact method. If the development of secondary glaucoma is suspected, it is advisable to conduct electronic tonography.

Slit lamp examination

• Examination of the eyeball in lateral lighting. This method can detect symptoms of HRT such as eyeball injection, hyposphagma, non-through scleral wound, scleral foreign body.
• Biomicroscopy. This method can identify symptoms of direct hormone replacement therapy such as a non-piercing or scalped wound of the cornea, corneal erosion, corneal foreign body, hyphema, iridodialysis, tear of the pupillary edge of the iris, iridofacodonesis, vitreous hernia, subluxation of the lens (or IOL), dislocation of the lens (or IOL ) into the anterior chamber, aphakia, traumatic cataract; symptoms of complications of HRT - scar, edema, opacification, neovascularization and corneal cataract, hematocornea, rubeosis.
• Transmitted light examination. Based on the state of the reflex from the fundus of the eye, the transparency of the refractive media, mainly the vitreous body, is assessed (since changes in the cornea, anterior chamber and lens are easily diagnosed using biomicroscopy). A weakened or absent pink reflex, as well as a change in its color, indicate the presence of opacities in the refractive media of the eye.
• Biomicroophthalmoscopy using aspherical lenses of 60 and 90 diopters.Today, this is a priority method for diagnosing changes in the vitreous chamber and retina. With its help, such symptoms of HRT as hemophthalmos, retinal detachment, choroidal detachment, dislocation of the lens (or IOL) into the vitreous body, subretinal and intraretinal hemorrhage, retinal edema, retinal rupture (including macular), subretinal choroidal rupture are diagnosed directly; symptoms of complications of HRT - vitreous fibrosis, proliferative vitreoretinopathy, choroidal neovascularization, subretinal and epiretinal fibrosis.
• Study using a three/four mirror Goldmann lens.This method allows you to visualize parts of the corneal-iris angle (CRU) and retrolentals that are inaccessible for inspection by other methods. peripheral parts glassy chamber. With its help, symptoms of closed eye injury and its complications such as cyclodialysis and neovascularization of the RRU can be diagnosed.

Symptom F.V. Pripechek. This simple symptom is very important in the initial diagnosis of an injured eye. In the presence of confluent hyposphagma, which does not allow visual assessment of the integrity of the underlying sclera with a glass rod after epibulbar anesthesia, pressure is applied to the sclera in the projection of the hyposphagma. Cutting pain syndrome supports the diagnosis of occult scleral rupture open injury eyes.

Diaphanoscopy - It is carried out using a diaphanoscope in the version of transscleral or transpupillary diaphanoscopy and pAllows you to identify subconjunctival rupture of the sclera as a symptom of open eye injury, as well as a symptom such as cyclodialysis.

Ultrasound diagnostic methods.

• A two-dimensional B-scan is more informative for HRT than a one-dimensional A-scan. The main indication for its use is a violation of the transparency of optical media, precluding the use of optical methods for visualizing intraocular structures. Ultrasound scanning allows you to determine the state of the intraocular media and membranes: the degree of hemophthalmos, the presence and extent of retinal and choroidal detachment, and determine the position of the lens (or IOL).
• Ultrasound biomicroscopy (USBM) allows you to examine formations of the anterior segment of the eye and the iridociliary zone in opaque optical media and low ocular pressure.
• Ultrasound Doppler mapping of the eye allows you to determine the degree of circulatory disturbance in the vessels of the eye.

Optical coherence tomography (OCT) of the anterior and posterior segments of the eye .

OCT makes it possible to identify intravital changes in the cornea, structures of the anterior chamber and retina at the tissue level, and to objectify many subclinical symptoms, as well as to conduct morphometry of the identified changes. Tomographic symptoms of TTG directly include subretinal hemorrhages, retinal edema, macular retinal rupture, subretinal vascular rupture; with symptoms of complications of HRT - vitreomacular traction, choroidal neovascularization.

Radiography carried out to avoid damage to the orbital walls. If damage to the optic nerve is suspected, radiography is performed using the Rese method to identify pathology of the optic nerve canal.

Wider possibilities for visualizing orbital formations are provided by CT scan , allowing step-by-step precision to examine the walls of the orbit and its contents in case of severe trauma to the organ of vision and the middle third of the face, which is decisive in diagnosis and rehabilitation treatment orbital pathology.

Electrophysiological research methods (EPI)

• Electroretinography (ERG) allows you to objectively assess functional state various retinal structures:
  • Maximum (total) ERG – external (I and II neurons) sections of the entire retinal area; The method is highly informative for any violations of the transparency of refractive media.
  • Rhythmic ERG 30 Hz - I and II neurons of the cone system of the retina, indirect assessment of the functions of its central parts; The method is highly informative for any violations of the transparency of refractive media.
• Visual evoked potentials (VEPs) of the cerebral cortex allow us to objectively assess the functional state of the pathways. In case of TTG, flash-based VEPs are more applicable, the information content of which does not decrease (unlike pattern- and multifocal VEPs) when the transparency of the refractive media is impaired. Flash VEPs characterize the functional state of the macular orientation pathways.
• Electrical sensitivity (ES) of the retina is a subjective EPI method and is determined by the threshold current strength when it is applied to the eye being examined, causing the patient to experience a sensation of light (electrophosphene). EC primarily occurs in ganglion cells and characterizes the functional integrity of the pathways as a whole. An important advantage of the EC method is its high information content, regardless of the state of transparency of the refractive media and the state of the first and second retinal neurons.
• Lability (or critical frequency of phosphene disappearance (CCIF)) of the optic nerve refers to subjective EPI methods and is determined by the limiting (critical) frequency of flickering suprathreshold electrophosphene, at which the patient still distinguishes flickering light in the eye being examined. CCIF, like EC, primarily arises in ganglion cells and characterizes the functional preservation of the macular orientation pathways, i.e. axial beam. Normally, the CCIF should be more than 35 Hz.

Clinical manifestations

The clinical symptom complex of closed eye injury is very diverse and includes not only damage to the eyeball and its auxiliary organs, but also changes of a general nature.

All types of HTG are characterized by common pathogenetic processes such as neurocirculatory disorders in the form of vasospasm, vasodilation, increased permeability of the vascular wall, tissue edema, ischemia; instability of ophthalmotonus from reactive hypertension to severe hypotension. The multi-level nature of the lesion also causes biochemical changes and changes in the local immune status.

Shake most often it is an indirect hydrodynamic impact on the inner shell of the eyeball - the retina. There is an increase in the permeability of the vascular wall and, consequently, swelling often occurs not only in the diseased eye, but also in the healthy one. Vascular spasm, which occurs immediately after the injury, is replaced by their dilation, causing reactive hyperemia of the anterior part of the vascular tract.

On the retina, concussions most often appear as a Berlin opacification in the center or periphery, and sometimes it stretches in a wide strip along large vessels. If the opacities are located in the center, they often cover the area of ​​the optic disc, and around the disc they are less intense gray than at a distance of 1-2 disk diameters.

The intensity of the retinal opacification (from pale gray to milky white) can be used to judge the severity of the traumatic injury: the more intense the white color of the retina, the slower the opacities disappear. The cause of opacities is swelling of the interstitial substance of the retina. Often Prussian opacities do not cause a sharp decrease in visual acuity, but a concentric narrowing of the visual field is always observed. The opacities disappear, usually within 7-10 days.

The change of media and membranes of varying density, contraction of the ciliary muscle in response to a blow, more dense attachment of the vitreous body at the optic nerve head and at the base of the vitreous body determines the location of ruptures and avulsions of the eyeball. More elastic membranes, such as the retina, are stretched, and less elastic membranes - the choroid, Descemet's membrane - are torn. With moderate traumatic effects, ruptures in the fundus are located concentrically with the optic disc; with gunshot contusions they have a polygonal location.

The variety of post-concussion conditions of the eye is due to the lability of the neuro-reflex system of the eye; changes in ophthalmotonus and reverse development of damage during contusion against the background of secondary reactive inflammatory and degenerative processes.

All contusion lesions are accompanied by hemorrhages. These are retrobulbar hematomas, eyelid hematomas, subconjunctival hemorrhages, hyphemas, iris hemorrhages, hemophthalmos, preretinal, retinal, subretinal and subchoroidal hemorrhages.

Hyposphagma- To hemorrhage under the conjunctiva is easily diagnosed in the form of a varying area of ​​red subconjunctival lesion. Extensive hyposphagmas can occupy large areas up to the entire surface of the eyeball and extend above it. Hyposphagma itself is not dangerous, since it does not cause vision loss and resolves over time without a trace. However, it is extremely important to remember that an extensive hyposphagma can shield a subconjunctival scleral tear (which would reclassify the injury as an open eye injury). Excluding a through rupture of the sclera with extensive hyposphagma is a priority diagnostic task, including determination of the Pripechek symptom, diaphanoscopy, and revision of the sclera

Hyphema – the level of blood in the anterior chamber occurs due to a rupture of the iris at its root or in the pupillary area. With hyphema, imbibition of the cornea by hemoglobin often occurs, since particularly favorable conditions are created for the development of hemolysis, as well as for disruption of outflow intraocular fluid due to both total hyphemas and traumatic injuries tissues in the corner of the anterior chamber blocking the outflow tract.

Hyphemas are divided into primary and secondary, each of which can be partial, subtotal and total.

Erosion occurs on the cornea with partial or total absence of epithelium.

With contusive damage to the iris, traumatic mydriasis may develop due to sphincter paresis, which occurs almost immediately after traumatic exposure. The reaction of the pupil to light is lost, its size increases to 7-10 mm. In this case, patients complain of photophobia and decreased visual acuity. Paresis of the ciliary muscle during contusion leads to accommodation disorder. With strong impacts, partial or complete separation of the iris from the root is possible (iridodialysis), resulting in aniridia. In addition, radial ruptures of the iris and separation of part of it with the formation of sectoral defects are possible. When the vessels of the iris are damaged, hyphema occurs, which can be partial or complete.

In some cases, damage to the anterior wall of the ciliary body and splitting of the ciliary muscle are observed. Together with the iris and lens, the longitudinal fibers of the ciliary muscle move back, and the iridocorneal angle deepens. This is called anterior chamber angle recession, which is the cause of secondary glaucoma.

In case of contusion, due to short-term contact of the iris with the anterior capsule of the lens, an imprint of the pigment layer of the iris - the Vossius ring - may form on it.

Any traumatic effect on the lens, even without violating the integrity of the capsule, can lead to opacities of varying severity. When the capsular bag is preserved, subcapsular cataracts often develop with localization of opacities in the projection of the application of traumatic force in the form of a frosty pattern on the glass.

Blunt trauma often results in pathology of the ligamentous apparatus of the lens . Thus, after exposure to a damaging factor, subluxation (subluxation) may occur, in which part of the zonules of Zinn ruptures, but with the help of the remaining sections of the ciliary girdle, the lens is held in place. With subluxation, a disorder of accommodation is observed, and lens astigmatism may occur due to uneven tension of the lens bag by the remaining ligaments. A decrease in the depth of the anterior chamber during subluxation can impede the outflow of aqueous humor and cause the development of secondary phacotopic glaucoma.

A more severe condition is dislocation (luxation) of the lens into the anterior chamber or into the vitreous. Luxation into the anterior chamber leads to the development of secondary phacomorphic glaucoma with very high ophthalmotonus values ​​due to complete blockage of fluid outflow from the eye. The lens can dislocate under the conjunctiva when the sclera ruptures in the limbus.

In all cases of lens dislocation, a deep anterior chamber is noted, and iris trembling is possible - iridodonesis.

Severe manifestation of contusion of the eyeball, hemorrhage into the vitreous body. Hemophthalmos can be partial or complete. Hemophthalmos is diagnosed by examination in transmitted light. In this case, the fundus reflex is weakened or absent. Poorly resolving hemophthalmos can lead to the formation of adhesions (shvart) with the retina and subsequently to tractional retinal detachments.

Of the many retinal tears, contusion ones are most characterized by either “activation” of a previously existing “silent” break, or the formation at the moment of impact of a new break in places of dystrophy or vitreoretinal traction, or an extensive separation of the retina from the dentate line. Depending on the location of the ruptures, visual acuity decreases varying degrees, retinal detachment occurs and spreads.

Macular hole ophthalmoscopically defined as a rounded lesion, brighter red than the surrounding retina, in the projection of the macula. For transparent refractive media, optical coherence tomography provides the most diagnostic information. In case of violation of the transparency of refractive media early diagnosis traumatic macular hole is difficult.

Choroidal detachment (VSD)- T traumatic AOM is hemorrhagic and occurs due to rupture of the choroidal vessels at the time of injury. Clinically, it manifests itself as rounded domes of varying sizes protruding into the vitreous chamber. Differential diagnostic differences from retinal detachment are the color of the domes (dark pink or dark red, not matte) and immobility when moving the eyeball. With concomitant hemophthalmia, when ophthalmoscopy is uninformative, a B-scan is used, which identifies a stationary echo-positive round shadow in the posterior pole of the eyeball.

Subretinal rupture of the choroid is the result of compression deformation of the eyeball in the sagittal plane at the time of injury. If a rupture of the choroid occurs, then due to the natural elasticity of the choroid and the reverse longitudinal stretching of the eyeball, the edges of the rupture diverge. Due to diastasis of the edges of the gap, an achoroidal zone appears, where there is no perfusion of the retina and local retinal ischemia occurs. Ophthalmoscopically, white sickle-shaped lesions with clear contours are determined, usually located concentrically with the optic disc. Frequent localization of breaks in the macular region is due to the smallest thickness of the vascular tissue in this zone. With TTG, two or more ruptures are often detected, located parallel to each other. A common complication subretinal vascular rupture is local subretinal hemorrhage. With macular localization, this pathology leads to pronounced sharp decline vision.

One of the most severe complications of HRT is traumatic neuroopticopathy when, as a result of contusion of the optic nerve, vision is reduced to the point of blindness while the eyeball is intact. The clinical picture is extremely poor, since sometimes there are no changes in the eyeball at all. There may be a relative narrowing of the arteries. In the presence of other manifestations of TTG described above, an alarming symptom is the discrepancy between intraocular changes and a significant degree of vision loss. In cases of pronounced intraocular manifestations of TTG (significant hemophthalmos, traumatic cataract, total hyphema, etc.), it is very important not to miss the concomitant traumatic neuroopticopathy. Mandatory elements of diagnosis should be entoptic phenomena (AOS, mechanophosphenes), the absence of which indicates pathology of the visual-nervous pathway, as well as the study of electrophosphenes. In these cases, an increase in EC thresholds and a decrease in CCIF directly indicate contusional neuroopticopathy.

Treatment

Depending on the totality of pathological changes in each specific clinical case, treatment of a closed injury can be only conservative or combine surgical and conservative components; may be local or combine systemic and local therapy.

Emergency surgical intervention carried out at

• Subconjunctival tears of the sclera and cornea
• Revision of the sclera for suspected subconjunctival rupture
• Lens luxation into the anterior chamber
• Total hyphema and hypertension

General principles of treatment for mild contusion

• outpatient mode
• antibacterial drugs
• anti-inflammatory drugs (instillations of dexamethasone, naklof)
• dehydration therapy (diacarb)
• angioprotectors (dicinone, ascorutin)
• symptomatic therapy for erosions: antibiotics in instillations, agents accelerating epithelialization (balarpan, Vitasik, Actovegin)

General principles of treatment for moderate and severe concussion

• stationary mode
• sedatives (Relanium, phenazepam)
• antibacterial drugs
• anti-inflammatory therapy (corticosteroids - dexamethasone, NSAIDs - indomethacin, ibuprofen)
• dehydration therapy (diacarb, lasix, 40% glucose solution)
• enzyme therapy (fibrinolysin, lidase, hemase)
• immunocorrective therapy (Imunofan)
• angioprotectors (dicinon, stugeron)
• antioxidants (tocopherol, emoxypine)
• detoxification therapy (reopoliglucin, hemodez, methenamine)
• agents that improve microcirculation (trental, a nicotinic acid)
• symptomatic therapy (hypotensive drugs, analgesics)

In case of traumatic damage to the retina and optic nerve, it is carried out in a hospital using a variety of medications, lasers, operations for retinal detachment.

When intraocular pressure increases, various drugs are used to reduce it (drops). If drops are not effective enough, laser or microsurgery is used. Patients with increased intraocular pressure should be monitored at the dispensary and systematically receive various courses of treatment. If not detected in time high blood pressure The optic nerve is affected, and its atrophy develops, leading to a narrowing of the field of vision and blindness. It should be remembered that lost vision secondary glaucoma does not recover, so it is necessary to monitor injured eye, be periodically examined by an ophthalmologist.

Long-term low intraocular pressure is also dangerous for the eye and can lead to blindness in 4% of patients. Exist complex methods Treatment of such hypotension is medicinal and surgical, allowing to normalize intraocular pressure.

A retinal tear is a violation of the integrity of the retina of the eye, leading in most cases to its detachment. The retina is the light-sensitive membrane of the eye no more than one-sixth of a millimeter thick. It fits tightly to the vitreous body and is attached to it along the dentate line. Due to various reasons gaps may form at the contact points. Causes The causes of retinal rupture can be supplemented by factors that aggravate the current situation and lead to the progression of ruptures and the development of retinal detachment. These factors include: Large exercise stress; Sharp bends and jumps; Head injuries; Severe stress; Increased blood pressure Symptoms Unexpected “lightning” or flashes of light, most often occurring in dark rooms. This phenomenon is explained by tension inner shell eyes in the area of ​​the rupture; The appearance of flies before the eyes. This may be a manifestation of posterior vitreous detachment or a sign of vitreous hemorrhage due to rupture blood vessel together with the retina; Deterioration of vision, manifested as a narrowing of the field of view or distortion visible objects. Explained by the formation of a macular hole in the retina or the progression of retinal detachment that has reached the area central vision; The appearance of a curtain before the eyes, forming on one side. This is a sign of the presence of a rupture and already begun retinal detachment. In the presence of this symptom You must immediately contact an ophthalmologist, as delay may lead to total loss vision. Decreased visual acuity or asymptomatic course, history of trauma. On examination, one or more yellowish or white crescent-shaped streaks are found under the retina, which are predominantly located concentrically to the optic nerve head. Often the rupture does not become noticeable until several days or weeks after the injury because it may be masked by hemorrhage. \ Diagnostics 1. Complete ophthalmological examination, including examination of the fundus with a dilated pupil to diagnose a traumatic rupture of the choroid. CNVM is best seen with a slit lamp and either a 60- or 90-diopter fundus contact lens. 2. Fluorescein angiography can be used to confirm choroidal rupture or determine CNVM. Treatment There is preventative treatment for retinal tears. As such, a gap, unfortunately, cannot be cured, so all efforts are aimed at preventing retinal detachment. The main treatment method is restrictive laser coagulation. The surgeon uses a laser to “solder” the retina around the tear, thereby forming a barrier that prevents the detachment from spreading. If you do not see a doctor in a timely manner, when a significant area of ​​the retina has detached, you have to resort to more complex operations.