15-10-2012, 14:25

Description

The magnitude of the pupil is determined by the balance between the sphincter and the iris dictator, the balance between the sympathetic and parasympathetic nervous system. Sympathetic fibers nervous system Innervat the iris dilator. From the sympathetic plexus of the inner carotid artery, the fibers penetrate into orbit through the upper orbital slit and in the composition of long ciliary arteries innervat the iris dilator. A greater the magnitude of the pupil is maintained by a parasympathetic nervous system that innervates the sphincter of the iris. It is parasympathetic innervation that the pupil response is supported. Efferent pupil fibers in the composition of the ooo eye nerve enter orbit and are suitable for ciliary ganglia. Postsynaptic parasimnatic fibers in the composition of short ciliary nerves are suitable for the spherical of the pupil.

The magnitude of the pupil is normal, according to various authors, fluctuates in the range of 2.5-5.0 mm, 3.5-6.0 mm. Perhaps such oscillations are due not only to the age of the surveyed, but also research methods. Newborn and older people are inherent in a narrower pupil. With myopia, eyes with light iris have wider pupils. In 25% of cases, an aisocoria is found in the overall population - the difference in the diameter of the pupils of one and another eye; However, the difference in diameter should not exceed 1 mm. Anisocoria over 1 mm is regarded as pathological. Since the parasympathetic innervation of pupils from the EDinger Westphal kernel is bilateral, estimate a direct and friendly response to light.

The direct reaction of the pupil to the light is on the side of the eyed eye, a friendly reaction to the light - the reaction on another eye. In addition to the reaction of the pupil to light, the reaction to the convergence is evaluated.

Justification

The magnitude of the pupil, its reaction to light and the convergence reflect the condition of its sympathetic and parasympathetic innervation, the state of the oath nerve and serve as an important indicator of the functional activity of the brain barrel, the reticular formation.

Indications

To diagnose the brain tumor, hydrocephalus, cranial injury, brain aneurysms, inflammatory processes brain and its shells, syphilis CNS, injuries and volumetric orbits, neck injuries and consequences of transferred carotid angiography, tumors of the slope of the lung.

Methodik

It is necessary to estimate the state of pupils in both eyes simultaneously with diffuse illumination, directing the light parallel to the patient's face. At the same time, the patient should look into the distance. Such lighting contributes not only to the assessment of the pupil, its diameter, forms, but also to the detection of anisocoria. The size of the pupil is measured using a fupilometric or millimeter line. On average, it is 2.5-4.5 mm. The difference in the magnitude of the pupil of one and the other eye is more than 0.9-1.0 mm regarded as a pathological anisocorium. To explore the pupil reaction to the light, which is better to spend in a dark or darkened room, alternately evode each eye separately the light source (flashlight, manual ophthalmoscope). Determine the speed and amplitude of the line (on the eyed eye) and a friendly (on another eye) of the reaction of the pupil.

Normally, the direct reaction to the light is the same or somewhat less friendly than friendly. To estimate the pupil reaction to light, four gradations are usually used: a living, satisfactory, sluggish and lack of reaction.

In addition to the reaction to the light, the reaction of the pupil to the act of convergence is evaluated (or, as they write in foreign literature, close to the distance). Normally, pupils are narrowed by the information of the eyeballs on the convergence.

Giving an assessment of pupils, a pupil reaction to light and convergence, it is necessary to exclude pathology from the iris and the pupil edge. For this purpose, the biomicroscopy of the front segment of the eye is shown.

INTERPRETATION

One-sided mydriasis with a meflexia of pupil into light (symptom of the clivical edge) - a sign of the defeat of the glasses. In the absence of glazation disorders, its pupillomotor fibers at the level of the brain barrel (nerve root) or nerve barrel at the place of its head of the brain are affected. This symptomatology may indicate the formation of hematoma on the side of the lesion or the growing brain edema or be a sign of the dislocation of the brain of other etiologies.

Midship with a straight and friendly reaction to light in combination with restriction or absence of mobility eyeball Up, down, Knutsa testifies to the damage to the root or the trunk of the Oculotory nerve (N. Oculomotorius - III cranial nerve). Due to the restriction of the mobility of the eyeball of the eye apple, a paralytic diverging strabismus develops. In addition to eye violations, partial (polulus) or full ptosis are observed upper century.

Defeat spectator nerve any etiology with the development of visual disorders from a minor reduction in visual acuity to the amabase may also cause one-sided mydriasis with the manifestation of the symptom of Marcus Hunna (afferent pupil defect). At the same time, an aisocoria, in contrast to the cases of the lesion of the o'clock nerve, it happens to a pronounced, mydriasis on the side of the defeat from a small to moderate. In such cases, the assessment is important not only the direct reaction of the pupil on the light on the side of the mydriasis, which, depending on the degree of lesion of the optic nerve, is reduced from satisfactory to its absence, but also a friendly reaction of the pupil to the world both on the face of mydriaz and another eye. Thus, in mydriasis, due to the lesion of the pupil sphincter, the straight and friendly reaction of the pupil of another eye will be preserved, while in a patient with an afferent pupil defect (symptom of Marcus-Gunn), a friendly reaction of the pupil on the side of the mydriasis will be stored in violation of the friendly reaction of another eye .

Tonic pupil (adie "s pupil)- A wide pupil on one eye with a sluggish sectoral or practically missing reaction to light and a more saved reaction to convergence. It is believed that the tonic pupil is evolving as a result of the defeat of ciliary ganglia or / and postganglyonary parasympathetic fibers.

Eidida syndrome - Areflexia pupil on the background of his mydriasis. U. develops healthy people, meets more often in women aged 20-50 years. In 80% of cases, it is unilateral in nature, may be accompanied by complaints about the lights. The patient sees well both in the distance and close, but the act of accommodation is slowed down. Over time, the pupil is spontaneously declining and accommodation improves.

Bilateral Midryaz Without a pupil reaction to light, there is a damage to both visual nerves and a bilateral amavrica, with a bilateral damage to the glasses of the head of the brain - the lesion of the nucleus, the root or the trunk of the glasses on the basis of the brain).

Violation of the reaction (direct and friendly) pupil into light In both eyes, up to its absence, with the normal diameter, the pupil happens when the pretextal zone is damaged, which is observed at hydrocephalus, ventricular tumors III, mid-brain. Inactivation parasympathetic system As a result, for example, inadequate cerebrovascular perfusion, which is possible due to the secondary hypotension in the loss of blood, can also lead to bilateral meydria.

One-sided MIOS.indicates the prevalence of parasympathetic innervation over the sympathetic. Typically, one-sided myiosis comes from a city horn syndrome. In addition to Mios, the syndrome develops ptosis and enofallas (as a result of a reduction in Muller's muscle innervation) a small conjunctival irritation. The reaction of the pupil to the light almost does not change.

Bilateral MIOS., practically not expanding when instillations of mydriatics with a sluggish reaction to light and normal on the convergence, the manifestation of Argail Robertson syndrome is recognized as pathognomonic for syphilitic damage to the central nervous system.

Bilateral MIOs with a preserved reaction to light It indicates the defeat of the brain stem and may be the result of a structural or physiological inactivation of a sympathetic path descending from the hypothalamus through the reticular formation. In addition, bilateral mios may assume metabolic encephalopathy or drugs.

Differential diagnosis

Afferent pupil defect(Pupil Marcus-Gunna) is characterized by one-sided mydriasis, a violation of a direct reaction to light on the side of the lesion and a violation of a friendly reaction to light on another eye. Midryaz, as the manifestation of the lesion of the glasses, usually combines the violation of the eye mobility up, down and knutut, as well various degrees Polandtosis or ptosis of the upper eyelid. The lesion of only the fupillomotor fibers of the ocudious nerve is manifested by one-sided mydriasis with a disturbed direct and friendly reaction to light on the affected eye and normal photoreacts on another eye. With the damage to the mid-brain structures, the violation of the pupil reaction to the light symmetrically in both eyes. At the same time, the diameter of the pupils is not changed and the pupil-narrowing reaction to the convergence (Light-Near Dissociation) is maintained.

Tonic pupil (ADIE "SPUPIL), in addition to one-sided mydriasis, is distinguished by a sluggish sectoral reaction to light (direct and friendly), which is better determined by study using a slit lamp, and a relatively saved pupil reaction to convergence. However, you need to remember that the Midship and Violations need to be remembered. The pupil photoreacts may be due to the damage to the sphincter of the pupil and pathology in the iris.

A distinctive feature of a one-sided Miode with a horner syndrome compared to miosis with Irite - the safety of photoreacts and a combination of a mine with partial ptosis and enofalm.

IN differential diagnosis Pharmacological samples (on pilocarpine, cocaine) play a certain role.

Article from the book :.

Stimulation of parasympathetic nerves Also excites the circular muscle of the iris (pupil sphincter). When it is reduced, the pupil is narrowed, i.e. Diameter it decreases. This phenomenon is called myiosis. Conversely, the stimulation of sympathetic nerves excites radial fibers of the iris, causing an expansion of a pupil called mydriasis.

Pupil reflex. Under the action of light on the eye, the diameter of the pupil decreases. This reaction is called a pupil reflex to light. The nerve path of this reflex is shown at the top of the black arrows pattern. When the light enters the retina, a small number of emerging pulses passes through a visual nerve to the pretextal nuclei. From here, secondary impulses go to the Vestfhal-Edinger's core and in the end - back through the parasympathetic nerves to the sphincter of the iris, causing its abbreviation. In the dark, the reflex is braked, which leads to the expansion of the pupil.

Function of light reflex - Help the eye is extremely quickly adapted to changes in illumination. The diameter of the pupil varies in the range from about 1.5 mm at a maximum narrowing of up to 8 mm with a maximum expansion. Since the brightness of light on the retina increases in proportion to the square of the pupil diameter, the range of light and dark adaptation, which can be carried out due to the pupil reflex, is about 30: 1, i.e. The amount of light included in the eye, due to the pupil, can vary 30 times.

Reflexes (or reaction) pupil with damage to the nervous system. Under some lesions of the central nervous system, the transfer of visual signals from the retina to the Westfal-Edinger's kernel is disturbed, which blocks pupil reflexes. This blockade occurs often as a result of syphilis of the central nervous system, alcoholism, encephalitis and other lesions. Typically, the blockade occurs in the pretended area of \u200b\u200bthe brain barrel, although it can also be the result of the destruction of some thin fibers of the visual nerves.

Fibers coming from prepractical nuclei to the core of Westfal Edinger, mostly brakes. Without their braking influence, the kernel becomes chronically active, causing a constant narrowing of the pupil, along with the loss of reaction.

Moreover, pupils It can be stronger than normal, when stimulating the Westfhal-Edinger kernel in another way. For example, when the eyes are fixed in the near object, the signals causing the accommodation of the lens and the convergence of two eyes, at the same time lead to a minor narrowing of the pupil. This is called the reaction of the pupil to the accommodation. The pupil that does not respond to light, but reacts to accommodation and at the same time severely narrowed (the pupil of Argilla Robertson) is an important diagnostic symptom of damage to the central nervous system (often syphilitic nature).

Syndrome Gorner. Sometimes there is a violation of the sympathetic innervation of the eye, which is often localized in the cervical sympathetic chain. This causes a clinical state, called the horner syndrome, the main manifestations of which are the following: (1) the pupil remains constantly narrowed due to the interrupting of the sympathetic innervation of the muscle expanding it, compared with the pupil of the opposite eye; (2) upper eyelid It is omitted (normal it is maintained open in the waking hours partially by reducing smooth muscle fibers embedded in the upper eyelid and innervated sympathetic nervous system).

In this way, destruction of sympathetic nerves makes it impossible to open the upper ages so widely as normal; (3) on the side of the defeat blood vessels Persons and heads are constantly expanded; (4) Lack of sweating (which requires sympathetic nerve signals) in the field of face and head on the side, affected by the horner syndrome.

Pupil reflexes

Normally, the pupils of both eyes are round, and their diameter is the same. With a decrease in overall illumination, the pupil reflexively expands. Consequently, the expansion and narrowing of the pupil is a reaction to a decrease and increase in overall illumination. The diameter of the pupil also depends on the distance to the fixed item. When translating a view from a long-range item to neighbor, pupils are narrowed.

In the iris, there are two types of muscle fibers surrounding the pupil: ring, innervated by parasimpatic fibers of the glasses, to which the nerves from the ciliary node are suitable. Radial muscles are innervated by sympathetic nerves, separated from the top cervical sympathetic node. The reduction of the first causes the narrowing of the pupil (MIOS), and the reduction of the second is the expansion (MIDRIAZ).

The diameter of the pupil and pupil reactions are important diagnostic signs for brain damage.

Then the lateral lighting method is investigated by the location, diameter of pupils, their form, uniformity, their reaction to light and close installation. Normally, the pupil is located a few books and knutrice from the center, the shape of the round, the diameter is 2-4.5 mm. The narrowing of the pupil may be as a result of injection of mystical tools, paralysis of the dlyatator, and most often the narrowing of the pupil is the most noticeable sign of the inflammation of the iris.

With age, the pupil becomes already. The expansion of pupils are observed after injection of mydriatics, during the paralysis of the ooo nerve. One-sided mydriasis may occur during a sphincter paralysis as a result of eye injury. Pupils are wider in eyes with dark iris and in myopia. The uneven magnitude of pupils (anisocorium) most often indicates the disease of the central nervous system. Incorrect form of pupil may be subject to the presence of a rear synech (the battle of the iris with the front capsule of the lens) or the front (the battle of the iris with the cornea).

To clearly make sure that the rear synechs are available, you should drip the means of expanding the pupil: 1% a solution of atropine or homatropine, 2% cocaine solution. Pupil expands in all directions, except those places where there are rear synechs. Thin synechnias as a result of the expanding action of these funds are broken, and on the site of the leakage on the front capsule of the lens can remain pigment specks and blocks of the smallest dimensions well visible by biomicroscopy.

In some cases, there may be a circular battle of the edge of the iris with an anterior capsule of the lens (SECLUSIO Pupillae) and then, despite repeated instillation of atropine, it is impossible to cause the expansion of the pupil. Such complete rear synechia leads to an increase intraocular pressurebecause Disconnection of the front and rear chamber interferes intraocular fluid to circulate normally.

Liquid accumulates B. rear chamber, Provides a rainbow shell forward (IRIS BOMBEE). To the same state may result in an exudate pupil (Occlusio Pupillae). Sometimes it is possible to see the wrap-shell tissue defect - the coloboma iridis (Fig. 16), which may be congenital and acquired. Congenital are usually located at the bottom of the iris and give the pupilly stretched, pear shape.

Acquired colobroms can be created artificially as a result of an operation or caused by injury. Postoperative colobums are most often in the upper part of the iris and can be complete (when the iris is missing in any sector completely from the root to the pupil edge, and the pupil acquires the shape of a key well) and partial having a form of a small triangle near the root of the iris. From the peripheral colobroma, it is necessary to distinguish between the iris in the root as a result of injury.

The reaction of the pupil is better to check in a dark room. For each eye, the light beam is directed separately, which causes a sharp narrowing of the pupil (direct response of the pupil to light). When illuminating the pupil of one eye at the same time, the pupil of another eye is sick - this is a friendly reaction. The pupil reaction is called "alive" if the pupil is narrowing quickly and distinctly, and "sluggish" if it is narrowing slowly and not enough. Pumping reactions to light can be carried out with multiple daylight and with a slit lamp.

When checking the pupil on accommodation and convergence (close installation), the patient is offered to see the distance, and then translate the eyes on the finger, which explore keeps the patient from his face. In this case, the pupil must be permanently.

Earlier it has already been said that pupils can be expanded when instilled off medicinal substancescausing paralysis of the sphincter (atropine, homatropine, scaffolds, etc. or the excitation of a dlyatator (cocaine, ephedrine, adrenaline). The expansion of pupils is observed when taking inside preparations containing belladonnu. At the same time, there is a lack of a reaction of the pupil into light, a decrease in view, especially When working at close range, as the result of the accommodation car.

For anemia, pupils can also expand, but their reaction to the light remains good. The same is observed in myopia. A wide fixed pupil will be with blindness caused by the damage to the retina and the optic nerve. Absolute immobility of pupils occurs with the damage to the glasses.

If an extended and fixed pupil is the result of a paralysis of the glasses with a simultaneous lesion of fibers going to the ciliary muscle, accommodation will also be paralyzed. In this case, the diagnosis of internal ophthalmoplegia is made. This phenomenon can be under cerebral syphilis (the core of the ooo oxide nerve is affected), with brain tumors, meningitis, encephalitis, diphtheria, orbit diseases and during injuries, accompanied by the lesion of the o'cloth nerve or ciliary assembly. Chine irritation sympathetic nerve maybe with increasing lymph node on the neck, with the top focus in light, chronic pleurite, etc. And causes a one-sided expansion of the pupil. The same expansion can be observed in Siringomyelia, polio and meningitis, affecting the lower cervical and upper thoracic spinal cord. The narrowing of the pupil and its immobility can be caused by mystical means, acting on the muscle, narrowing the pupil (Pilocarpine, Ezerin, Armin, etc.).

With lateral lighting, a normal crystal is not visible due to its full transparency. If there are separate clouding in the front layers ( initial cataract), then with lateral lighting, they are visible on a black background of pupil in the form of separate grayish strokes, points, teeth, etc. With full turbidity lens (cataract), the whole pupil has a mute gray.

In general, to identify the initial changes in the lens and the vitreous body, the method of passing light is used. The method is based on the ability of the pigmented eyeboard to reflect the light beam aimed at it. The study is made in a dark room. Matte electric lamp 60-100 W should stand on the left and behind the patient at the level of his eye. The doctor approaches the patient for a distance of 20-30 cm and with the help of an ophthalmoscope attached to his eye directs the light into the eye under investigation.

If the crystalik I. vitreous body Transparent, the pupil glows with red light. The red light is explained in part of the blood shell blood transmission, partly the red-brown shade of the retinal pigment.

The patient is offered to change the direction of the gaze and whether the uniform red reflex from the eye bottom is observed. Even minor turbidity in transparent eye environments detains the rays reflected from the eye bottom, as a result of which dark areas appear on the red background of the pupil, corresponding to the location of the clouding. If a preliminary study during lateral lighting did not find any clouds in the front eye, then the appearance of the dimming on the red background of the pupil should be explained by the clouds of the vitreous body or deep layers of the lens.

Lounge lens have the form of thin dark spokes directed to the center from the equator of the lens, or individual points, or star-diverging from the center of the lens. If these dark points and strips are moving with the movements of the eye with the movements of the eyeball, then the cloues are located in the front layers of the lens, and if they are lagging behind this movement and seem to be moving as if in the opposite direction of eye movement, then the cloues are in the rear layers of the ledelik. Lounge, located in a vitreous body, in contrast to the closets of the lens, have incorrect acknowledged odds. They seem to be web or have the kind of networks, fluctuating at the slightest movement of the eyes. With intense, thick clouds, massive hemorrhages in the vitreous body, as well as with total turbidity of the lens, the pupil during the study does not shine in the transmittance, and the light of the pupil is white. All departments of the eye are more accurately investigated by biomicroscopy, lens using the device anterior segment analyzer.

A person is sensitive to light irritants.

If this does not happen, then a doctor may have a lot of suspicion.

There are a large number of factors that can cause such a pathological process.

It is mainly due to the presence of congenital diseases or injuries. It is important to explore in detail clinical pictureSince it has similarities with different ophthalmological diseases. The doctor must appoint a full-fledged examination, and then identify ways of treatment.

How pupils should react to light

In most cases, pupils expand under the action of bright light. Any impact on the eyes can have negative consequences. If the reaction to the light does not arise, it will be necessary to see a doctor. It is important to take into account that pupils can and narrow when exposed to too bright light. Do not forget about the individual characteristics of a person. The structure of the eyes, reactions and vision for everyone may have unusual features. With certain pathologies, one eye can respond to light, and the other is not.

The reasons

When an extended pupil does not respond to light, it should be a reason for anxiety. The patient should visit the specialist as soon as possible. Such violations may be associated with many factors:

• injuries of the nerves that are responsible for mobility visual organs;
• visual difference of pupils;
• pupil sphincter injuries;
• long use Some medicines.

In some cases, pupils narrow or expand under the influence of emotional state. Considering age-related changes, the pupil may not be sufficient enough. This is associated with a decrease in sensitivity. Often, doctors say that narrow pupils are not in all cases are a sign of pathology.

This may be due to the impact of such factors:

• insufficient lighting indoors;
• the impact of strong positive or negative emotions;
• scientists argue that if a person looks at the other with love and sympathy, then there is a mydriasis.

It is possible to determine the true cause only after a careful inspection of visual organs.

Possible diseases

Bright light can affect the state of pupils in each person differently. If the symmetry of the face is correct, then the presence of pathology can be excluded. In case of disease, human emotions have no natural look. It seems that a person grows his teeth, overly breeds her lips. If the body temperature does not increase, the limbs have the usual sensitivity, there is no nausea and vomiting, then the pathological process is absent.

Possible diseases:

• Defeat of optic nerve. In the absence of a reaction to the light of the blind eye, a friendly reduction of the pupil sphincter on another eye is observed.
• The defeat of the nerve that is responsible for the mobility of visual organs. In case of damage to the third nerve, there is a lack of direct, indirect and friendly reaction to light.
• Eddi syndrome. Often is the cause of violation of the reaction of pupils.

If a person observes the development of suspicious symptoms, you should immediately consult a doctor.

Diagnostics

To identify violations, the doctor conducts different surveys. Visual inspection:

• determination of the reaction of pupils into light;
• identification of accommodation abilities;
• evaluation of peripheral and central vision.

Additional examinations:

• biomicroscopy to study the condition of the lens and passing light through it;
• ophthalmoscopy for inspection of the ocular bottom and other structures;
• assessment of the condition of the iris;
• laboratory blood tests, feces, urine;
• CT and MRI with suspected internal pathology.

After the survey results, the doctor can determine the treatment method.

Treatment

The expansion or narrowing of the pupil into light is a normal reaction. If the pupil is absolutely not reacting to the light, then the etiology of such violations should be determined. This depends on the treatment method. If this is due to the presence of a disruption of fabric structures, then the doctor often recommends doing gymnastic eye exercises.

This will help strengthen their eyesight and restore a healthy and proper reaction. If the reasons are associated with the injury, then initially determine the state of the head, and then assign preventive measures for eyes.

If there are congenital pathologies, you need to choose medications Individually, given the etiology of the disease. It is important to take into account that self-treatment can cause the development of negative consequences. Therefore, at the first signs, you should contact the doctor and undergo a full-fledged examination.

Useful video

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Poor eyesight Significantly worsens the quality of life, it deprives the opportunity to see the world as it is. Not to mention the progression of pathologies and full blindness.

The study of the eye includes the definition of the magnitude and shape of the pupils, their reaction to the light (straight and friendly).

Samples of pupils on the light - to the samples of pupils for light include: direct, friendly reaction of pupils on light and reaction to convergence and accommodation.

The direct response to the light is determined by the following procedure: a patient sitting face to light, offered to close one eye with hand, and to watch in the distance in the distance. The surveyer closes the studied eye with his hand, it opens it by following the state of the pupil. Normally, with the darkening of the eye, the pupil expands, and when the lighting is narrowed. To determine a friendly reaction, dimming and illuminating one eye, follow the state of the pupil of another eye. Normally, the illumination of one eye causes the narrowing of the pupil not only of this eye (direct response), but also another (friendly reaction of the pupil to light). The presence of a friendly reaction to the light (the reaction to the light of both pupils when irritating the light of one of them) indicates the absence of severe damage to the middle brain.

When determining the reactions of pupils, attention should be paid attention to its speed. In case of sluggish reaction, it can be sensitiveized by pain pulses (plugs in the ear or in the neck).

In a number of diseases of the nervous system, weakening or lack of reaction of pupils are observed. The reaction of pupils on accommodation and convergence is that pupils are narrowed when the patient looks at the close distance and expand when he looks into the distance. To test this reaction, the examined is suggested to look at the tip of the doctor's index finger, then approaching it to the nose of the surveyed, then removing it.

You can explore the reaction of the pupil only to accommodation. For this, the patient is offered to close one eye with the hand, and to the other open eye to keep track of the tip of the doctor's index finger, which then brings it to the eye of the patient, then removes it. The patient looks at the close distance with one eye. There is no need for convergence at trial conditions, there is only an accommodation of one eye, which is also accompanied by a narrowing of the pupil.

The accommodation process of the eye is that the lens becomes more convex, thus increasing its refractive ability. In the process of accommodation, the ciliac muscle (accommodative muscle) is involved, which is innervated by a glamology nerve. So that the accommodation is carried out, the accommodative muscle is reduced, which entails the relaxation of the zinnow ligament of the lens and passive rounding it.

The most frequent pathological pupil reactions are the following: 1. Amavrotic immobility of pupils (loss of direct reaction in the blind eye lighted and friendly - in Final) occurs in the diseases of the retina and the visual path in which pupillomotor fibers are passing. The one-sided immobility of the pupil, developed by the amavrogen, is combined with a small expansion of the pupil, therefore an anisocorium occurs. Other pupil reactions do not suffer. With a bilateral amavrozosis, pupils are wide and not react to light. A variety of amavrotic immobility of pupils is hemianopic immobility of pupils. In cases of lesions of the visual tract, accompanied by a basal homonymous hemianopexy, there is no pupil reaction with a blind half of the retina in both eyes. 2. Reflex motility (see Argailla - Robertson Syndrome). 3. Absolute immobility of the pupil - the lack of a direct and friendly reaction of pupils into light and the installation for a close, develops gradually and begins with disorders of pupil reactions, mydriasis and complete immobility of pupils. The focus in the nuclei, roots, the trunk of the ice nerve, the ciliary body), the rear casual nerves (tumors, botulism, abscess, etc.).

45. Methods of performing anterior tamponade with nasal bleeding.

The main way to stop bleeding from the nose in cases where patients have no blood diseases, is a tamponade, which can be carried out fully only by a otorinolaryngologist. Only after it is carried out by some common medical events. Before the tamponade nose should be performed by its anesthesia. The nasal cavity is filled with a long gauze vaseline oil with a long gauze tampon 1-1.5 cm wide, which is injected with a nasal Corncang, curved tweezers or a thin hemostatic clamp with a nose mirror. If bleeding occurs only from the Kisselbach zone, then the front of the nose is shred, if the source is not installed from the depth or if the localization of the source is not installed, then the tampon fill the entire cavity of the nose, starting from the rear sections. In order to avoid the rear end of the tampon in the nasopharynk, it is proposed to enter a prosthesis of microporous rubber L-shaped form, which resembles a smoking tube. He is promoted to a depth of the bottom of the nose cavity to be widely ended. Then the gauze tampon fills the nasal moves above the level of the horizontal part of the prosthesis. Another way to prevent tampons in the nasopharynk is a tamponade of the nose multiple strips of gauze up to 8 cm on Beninghaus. They are placed on each other since the anticipation of the nose. With all the tight Tamponade one half of the nose, it is necessary to tampony and the second half to prevent the nasal partition offset in the opposite direction. With nasal bleeding, local fibrinolysis is activated with lying the resulting branches. In this regard, regardless of the cause of nasal bleeding in all cases, it is recommended to soak tampons with a 5% epsilon-aminocaproic acid solution. In case of violations of blood clotting, it is also advisable to separate thrombin, hemostatic sponge.