Medicines in ophthalmology. Where is the conjunctival sac of the eye located - treatment of diseases Rules for performing retrobulbar injection

Along with general treatment, local therapy is also widely used in ophthalmology. The most commonly used method is the administration (instillation) of eye drops.

Injection of eye drops into the conjunctival sac is carried out as follows. The sister takes the pipette in her right hand (Fig. 58). Fix the glass part of the pipette between the II and III or between the III and IV fingers, and the pipette between the thumb and forefinger and draw a few drops of medicine into the pipette. With the fingers of her left hand, in which there is a damp ball of cotton wool, she pulls back the lower eyelid (the patient looks up) and quickly puts 1-2 drops into the inner corner of the eye. You cannot turn the pipette upside down; it is best to hold it with the tip down at an angle of 45°. The pipette should not touch the eyelashes. No more than 1-2 drops can fit in the conjunctival sac. Drops remaining in the pipette should not be poured back into the vial. After putting drops into the eyes or putting ointment behind the eyelids, you must ask the patient to look down.

Rinsing the conjunctival sac. The conjunctival sac can be washed in several ways (Fig. 59.).
1. They let in not 1-2 drops, but 5-6 drops. Excess fluid flows out.

2. The lower eyelid is pulled back and the conjunctival sac is washed using an undine or rubber balloon. The liquid flows into a kidney-shaped basin, which the patient holds against his cheek. The eyelids are spread apart, sometimes turned inside out.

3. Pour the required solution into a special eye bath to the brim and, pressing the edges of the glass to the bony walls of the orbit, force the patient to blink.

4. Esmarch’s mug is suspended at a height of up to 1 m (so that the liquid flows out under some pressure) and the cavity of the conjunctival sac is washed from a rubber tube in case of chemical burns, dust, etc. To irrigate and cauterize the conjunctiva, turn out the upper eyelid, then bring it closer with the conjunctiva of the retracted lower eyelid (to cover the cornea to avoid burns), irrigate the conjunctiva with the necessary solution. Its excess is neutralized and washed off from the undine with physiological solution.

To put ointment into the conjunctival sac, take it on the spatula of a glass rod, pull back the lower eyelid and place a stick with ointment in the area of ​​the lower fornix (Fig. 60). Then the eyelids are closed, the glass rod is slowly removed to the side, and the eyeball through the eyelid is lightly massaged so that the ointment is distributed evenly.

Eye ointments are prepared with sterile Vaseline. To make the ointment more gentle, lanolin is added to Vaseline in equal parts. Ointments remain in the conjunctival sac longer than drops, and the fatty base of the ointment itself sometimes has a beneficial effect on the conjunctiva. Medicines used for ointments must be thoroughly ground. Emulsions are laid in the same way.

Some medications in the form of carefully crushed powders are injected into the conjunctival cavity. To do this, pull back the lower eyelid and powder the conjunctiva with a glass rod or cotton wool (sulfonamides, calomel, etc.).

Often the medicinal substance is injected directly under the conjunctiva of the eye or fornix, where a depot of these substances is created. After one or two instillations of a 0.5% dicaine solution, an injection of corticosteroids, novocaine, streptomycin, and penicillin is made under the conjunctiva. Autologous blood and oxygen are administered in the same way (oxygen therapy).

Sometimes the conjunctivae of the eyelids are lubricated with copper sulfate or alum in the form of eye pencils. In this case, you need to carefully check whether the eye pencil has any sharp edges. Before use, the pencil must be wiped with a damp cotton swab and a disinfectant solution.

Lubrication is used for trachoma and follicular conjunctivitis.

Rice. 58. Letting in drops.

Rice. 59. Rinsing the conjunctival sac.

Rice. 60. Laying ointment.

The study of the visual field (peripheral vision) is of great importance for the diagnosis and assessment of treatment results in many eye diseases associated with damage to the retina and optic nerve, as well as the central nervous system (retinal detachment, glaucoma, optic neuritis, damage to the visual pathways and centers) .

There are control and instrumental methods for determining the field of view. The visual field is always examined separately for each eye.

The control method is very simple and does not require special devices, the only requirement is that the boundaries of the field of vision of the examiner are normal. The technique is as follows: the doctor sits opposite the patient, the patient covers his left eye with his palm, and the doctor covers his right eye and look into each other’s eyes (the distance between the heads is about 50 cm). The doctor moves moving fingers or some other object from different sides (from the periphery to the center) at the same distance between himself and the patient. With normal boundaries of the visual field, the doctor and patient note the appearance of the object simultaneously.

Instrumental methods include perimetry. The most common is the Förster perimeter, which is a moving dark arc with a radius of curvature of 33 cm. The patient is blindfolded with one eye, he places his chin on a special stand so that the eye being examined is opposite the white point located in the center of the perimeter arc. A fixed white object measuring 0.5 - 1.0 cm, located at the end of a dark stick, is moved along a perimeter arc from the periphery to the center. First, the boundaries of the visual field are determined in the horizontal meridian (outside and inside), then in the vertical meridian (above and below) and in two oblique meridians. When examining the visual field from above, you must always lift the patient's upper eyelid with your finger, otherwise the data may be underestimated. At first, for control, the object can be moved quickly to determine the approximate boundaries, and the second time more slowly (at a speed of 2-3 cm per second). The degrees are indicated on the perimeter arc, which are transferred to a special bank.

The normal boundaries of the field of vision for white color are as follows: outside and below-outside - 90, below and inside - 60, below-inside - 60, above and above-inside - 55, above - outside - 70

The boundaries of the visual field are summed up along 8 meridians. Normally, the total field of view for each eye is 520-540. Test the visual field of both eyes on each other using the control method and using the perimeter.

A more accurate study of the field of view is carried out on projection perimeters of various types. To study visual field defects in its central parts, the campimetry method is used, but since this technique is labor-intensive and time-consuming, it is used only in a hospital setting.

Task No. 5: instillation of eye drops, application of ointments, application of monocular and binocular bandages, stickers on the eye.

Instillation of eye drops is one of the common methods of treating eye diseases. The procedure is simple, but requires certain skills. Methodology: Take drops with a 30% solution of Albucid (Sodium Sulfacyl), put the solution into a pipette, take a damp cotton swab (ball) in your left hand, pull the patient’s lower eyelid with it, bring the pipette to the eyeball and, without touching the eyelashes and eyes, drop 1-2 drops of Albucid solution into the inner corner of the lower conjunctival fornix. After instillation, press the projection site of the inferior lacrimal punctum with a ball.

ATTENTION: Before putting anything into your eyes, carefully read the name of the drug and the expiration date. Only eye drops can be put into the eye!

Laying ointments. Take a tube of one of the eye ointments (for example, tetracycline), squeeze a little ointment onto the flat surface of a glass rod, pull back the lower eyelid, insert the glass rod with ointment into the lower conjunctival fornix from the outside and ask the patient to close the eyelids, then remove the stick from the under the eyelid All the ointment remains in the conjunctival cavity, evenly distributed there. Remove excess ointment on the skin of the eyelid with a damp cotton swab (ball).

ATTENTION: Only ophthalmic ointment can be placed into the conjunctival cavity!

Bandage over one eye. For the bandage, bandages 6-7 cm wide are used. When applying a bandage to the right eye, hold the head of the bandage in the right hand and bandage from left to right; when applying a bandage to the left eye, it is more convenient to hold the head of the bandage in the left hand and bandage from right to left. The bandage is secured in a horizontal circular motion across the forehead, then lowered down to the back of the head, passed under the ear on the sore side, closing the eye, and secured in a circular motion over the head, then an oblique stroke is made again, but slightly higher than the previous one, and so on, alternating oblique and circular tours, cover the entire eye area.

Bandage on both eyes. The bandage is held as usual (the head of the bandage in the right hand), secured in a circular motion across the forehead, then lowered down along the crown and forehead and an oblique stroke is made from top to bottom, covering the left eye, the bandage is brought under the right ear, and then an oblique stroke is made from the bottom up. , covering the right eye. These and all subsequent moves of the bandage intersect at the bridge of the nose

The bandage is strengthened by moving the bandage in a circular manner across the forehead.

As with a monocular bandage, it is advisable to make a knot in the front or in front - on the side; to do this, tie the end of the bandage to the beginning.

Eye sticker. Cut two strips of adhesive plaster 8-10 cm long and 1 cm wide, place a clean cotton-gauze circle over the eye and secure it with strips of adhesive plaster to the skin of the face crosswise or parallel obliquely (skin of the forehead and cheeks).

Make sure your dressings look neat and aesthetically pleasing!

Content

The eyes are one of the most important sensory organs through which a person sees the world around him. They consist of the eyeball, visual system and auxiliary organs. One of the latter is the conjunctival sac, which is located between the lower and upper eyelids and the eyeball, while almost all drugs in the form of drops are instilled through this part of the eye.

What is the conjunctival sac

The eye sac is a cavity located between the eyelid and the eye. The apple and eyelid form its anterior and posterior walls, and the zones of their connection with each other form the conjunctival fornix. The definition of “conjunctival sac” was not given to the organ by chance: with the eyelids closed, it forms a closed cavity into which no more than 1-2 drops can fit.

The upper arch in an adult is deepened by 1 cm, and the depth of the lower one is 8 mm. The conjunctival cavity is covered with a smooth pink mucous membrane. And at the inner and outer corners it is red and loose, since it contains many vessels. An important function of the conjunctival cavity is the secretion of tear fluid, which helps remove debris that enters the eye and moistens the organ of vision.

Structural features

The cavity of the conjunctival sac is located between the eyeball and the eyelids. The space is surrounded above and below by the conjunctival fornix, and in front and behind by the membrane of the eyelids and the conjunctiva of the eye. With the eyelids closed, the organ is a closed bag, the peculiarity of which is its insignificant capacity (the cavity can hold no more than 1-2 drops). The conjunctiva fits tightly to the cartilage of the eyelids. The organ consists of:

• a shell formed from epithelial cells with a complex structure;
• irises;
• openings of the lacrimal canal (the function of the lacrimal glands is to moisturize the eyeballs with the help of the secretion produced);
• sclera;
• lower conjunctival fornix;
• lacrimal caruncle.

Where is

To understand where the conjunctival sac is located without a photo or diagram, you need to take any eyelid and pull it forward a little with your fingers: the resulting space will be the desired organ. The lower cavity of the lacrimal sac is located below, you can find it by moving the lower eyelid. Due to its unique structure, when drug solutions are instilled into the conjunctival sac, the drug reaches all corners, spreading over the surface of the eye, which occurs due to constant blinking.

What is it needed for

The conjunctival cavity is an important organ, as well as an integral component of the visual system. Functions it performs:

• Without it, treatment of eye diseases is impossible (if you drop the medicine into the space between the eyelids and the eyeball, the therapeutic effect is achieved after 15 minutes, since the drops quickly spread throughout the organs of vision, immediately beginning to act);
• in the conjunctival cavity, mucus and liquid are produced, which is contained in tears (this ensures hydration of the eye, prevents irritation, contamination or injury to the organ of vision).

What to do if you get a foreign body

If a speck or other foreign object gets into your eye, you can’t always get rid of it yourself. Because blinking can cause the body to scratch or even get stuck in the cornea, you should consult a doctor immediately. The faster the foreign object is removed from the eyelid cavity, the lower the risk of inflammation of the tear duct or the development of other complications. To perform the procedure at home, you need:

• wash your hands thoroughly with soap and file your nails;
• pull back the lower eyelid and carefully examine the surface of the conjunctival epithelium (the patient should look up);
• if the lint/speck is in the bag, you can get it out with the corner of a clean napkin;
• if a foreign body was not found in the lower part, it is worth inspecting the upper bag;
• You can see the speck that is located at the top if you slightly turn the upper eyelid outward, and the foreign object is removed in the same way;
• After the manipulation, it is recommended to apply special drops to the eye.

What diseases of the conjunctival sac exist?

Most pathologies of the conjunctival cavity are associated with improper hand and eye hygiene. As a rule, diseases such as conjunctivitis are more often diagnosed in children (the child’s eyelid is often rubbed with dirty hands, as a result of which the inflammatory process begins). What happens in this case:

• the inflammatory process is accompanied by burning, itching;
• lacrimation increases;
• pus accumulates in the folds of the eyelids and palpebral fissures (as a rule, the masses accumulate in the cavity of the lower eyelid).

Since this problem can be caused not only by infection, but also by allergies, before treating conjunctivitis, it is important to visit an ophthalmologist who will confirm the eye disease, determine its cause and prescribe adequate treatment for the patient. As a rule, therapy is carried out using eye ointments and drops. Since the sac, like the conjunctiva, is a delicate organ, even if a small speck gets in, infection and inflammation can begin to develop.

How to put drops into the conjunctival sac

The drug is instilled directly into the bag (into its lower fornix), since it can accommodate a larger volume of liquid than in the upper part of the cavity. With the help of blinking, the drops are quickly distributed over the entire surface of the eyeball, which ensures rapid absorption of the medicine and prompt manifestation of the pharmacological action. During instillation, the following important rules should be observed:

• wash your hands thoroughly with soap;
• Shake the bottle with drops vigorously before use;
• tilt your head back a little, push back the lower eyelid with your finger and drop 1-2 drops of the drug onto the front surface of the eye without touching the bottle to the organ of vision, then release the eyelid (it is better to point the pupil upward);
• keep your eyelids closed for a couple of minutes;
• the lacrimal sac forms a small tubercle at the inner corner, which must be gently pressed to remove any remaining medication;
• The eyes should be blotted with a clean napkin.

“The need to systematically administer one - and only one - drop into the conjunctival sac complicates the treatment of glaucoma. To ensure that patients follow the prescribed course of treatment and that medications remain effective, doctors should delve deeply into the patient’s problems and listen carefully to complaints. Clearer instructions will help avoid cases of inappropriate use,” said Dr. Alan Robin at Glaucoma Day, held as part of the Annual Congress of the American Academy of Ophthalmology. In 2014, this congress took place in Chicago.

According to the doctor, both doctors and patients are not yet fully aware of the scale of the problem. Alan conducted a study that clearly shows the conflict between patient opinion and evidence. Thus, 92% of respondents are convinced of the accuracy of their manipulations with drops. They said that they never dripped past, although observations indicate otherwise. De facto, 35% missed their eyes once, and more than a quarter of those surveyed regularly miss their eyes.

“First of all, we should be interested in whether the patient is having difficulties. Then it is reasonable to question the answer, especially if it is negative. It’s not that simple,” says Dr. Robin. Other common incidents include unwashed hands, contamination of the bottle, accidental injection of several drops, and excessively weak pressure when not a single drop reaches the eye.

According to the doctor, many ophthalmologists neglect to outline a clear instillation algorithm. The technique of using drops remains at the discretion of the patient. To illustrate his point, Dr. Robin highlighted the challenges that hinder effective home treatment.

Bottle design

A number of drops are released in inconvenient packaging, and the patient is often forced to use his teeth, or even a knife, to open them. This carries the risk of contaminating the contents of the bottle. Sometimes the neck can be pierced with the upper end of the cap, but this method is not completely comfortable for everyone. Many will prefer to cut off the neck of the bottle, making accurate dosing of volume and quantity fundamentally impossible. The difference in size and color of the bottles also confuses patients. “We hardly consider all these aspects during the prescription process,” Dr. Robin said.

Patient's physical strength

The force required for instillation varies according to the type of bottle. Not everyone can easily provide the required pressure (Drew & Wolffsohn; ARVO 2014).

“In the era of generics, we are seeing incredible diversity. Once you pick up several bottles, you will realize that they require different levels of pressure. And without a doubt, this affects the quality and effectiveness of therapy,” the speaker noted.

Drop size

The drop size of the generic drug is often different from the drop size of the brand name drug. If during treatment it was necessary to look for an analogue, the patient can empty the new bottle faster.

Infection

During instillation, many allow the tip of the bottle to come into contact with the cornea, which can lead to infection. According to Dr. Robin, there is no universal injection technique, but detailed instructions to the patient will never be superfluous. For a more detailed introduction to this problem, Alan offered a video recorded by Dr. Robert Rich (https://www.youtube.com/watch?v=FhkRAaIbIuE).

Sadly, ophthalmologists do not always pay due attention to instructions. A survey of 275 patients who made their first or subsequent visits to one of 17 specialists showed that only a few doctors make their appointments informative. Only 30.9% of examinations included verbal instruction, and demonstration of instillation techniques was provided in 9.8% of cases. The written explanation was drawn up by the doctor once at the request of the patient. “We have room to grow,” concluded Dr. Robin.