MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTANMEDICAL EDUCATION DEVELOPMENT CENTRE

TASHKENT MEDICAL ACADEMY

“Approved” byProrector on the academic workProf. Teshaev O.R._______________________________

«_____»________________2011 у.

Chair: EYE DISEASEES

Subject: OPHTHALMOLOGY

THEME:Diseases of a vascular layer. A cataract.

(For teachers and students of the higher medical institutions)

Educational-methodical workbook(For teachers and students of medical HIGH SCHOOLS)

Tashkent-2011.

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Authors: Abdurakhmanova U.M. - the assistant at eye diseasees chair ТМА.Reviewers: Professor Karimova M. H. – the deputy director on scientific work of the Eye Microsurgery

Center

Yangieva N.R. – the senior lecturer of chair of Eye Deseases of the ТМА

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THEME: Diseases of a vascular layer. A cataract.___________________________________________________________________1. THE PLACE OF CARRYING OUT OF EMPLOYMENT - Chair of eye diseasees; - Thematic patients, magnifier 13 D, a desk lamp, ophthalmoscope, anti-inflammatory drugs, antibi-otics, midriatics, slides, video films - slidoscope, TV-video.2. Duration of the lesson - 6 hours3. The purpose

It is necessary to know such pathologies of organ of vision, as diseases of vascular layer and a cataract for doctors of any specialties. Very often it is local display of many general diseases of an or-ganism: rheumatism, diabetes, tuberculosis, chronic and acute infectious diseases, a thyroid gland pathology etc. Doctors should be able to diagnose and treat patients with the pathology. It is necessary as to be able to carry out preventive measures of the possible complications arising at these diseases.

ProblemsThe student should know:- Classification of diseases of vascular layer and cataract; - Aethiopathogenesis and diagnostics of diseases of vascular layer and cataract; - Clinic and principles of treatment of diseases of a vascular layer and a cataract; - Complication and prophylaxis of diseases of vascular layer and cataract.The student should be able:

Practical skill – eyeball external examination, measurement of intraocular pressure by palpation.4. Motivation4. Motivation

Diseases of vascular layer (iridocyclitis, chorioiditis) are frequent reasons low vision and blind-nesses. Lens-dystrophic diseases lead to inpairement of properties of a crystalline lens - a transparency. Cataract are accompanied by sight fall, up to light sense. Low sight, as a rule, conducts to development of nistagmus and to a squint, and also to ambliopy. Unfortunately, cataract, is the most frequent reason of invalidisation of patients from the part of organ of vision.The theme will allow students to acquire the basic signs of disease of lens and vascular layer, their early diagnostics, ethiologic treatment and prophylaxis of complications and physical inability of pa-tients.

5. Intersubject and intrasubject relations5. Intersubject and intrasubject relationsKnowledge of students on the given theme should be characterised by sufficient width and

depth, and also interpretation with related subjects on «verticals and horizontals». The theme is inte-grated on a vertical with anatomy its section «nervous system and sense organs», with physiology – its section «physiology of nervous system», with histology – sections «ontogenesis and histology of ner-vous system and sense organs», with deontology – questions of mutual relations of patients and doc-tors, with medical history, including ophthalmological history, with pharmacotherapy in ophthalmol-ogy.

Across the ophthalmology is related to:- Otolaryngology (the anatomic neighbourhood and bilateral relation at various ENT pathology

and eye diseases); - With infections and their possible complications from the visual analyzer; - With internal diseasees (diseasees of blood and kidneys, collagenoses and others various com-

bined diseases with defeats of the visual analyzer; - With endocrinology - a diabetes, hypo-and hyperthirosis, diseases of a hypophysis and others

endocrinopathies; 6. The content of the lesson:

6.1 Theoretical partDiseases of the vascular (uveal) path. All three parts of a vascular path – iris, the ciliary body and ac-

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tually vascular layer – directly pass each other. An inflammation of these structures name accordingly iritis, cyclitis and chorioiditis; the term «uveitis» means any inflammation of the uveal path. The in-flammation of iris, iritis, usually is a consequence of other diseases if only there was no direct physical or chemical influence on iris itself. More often such diseases as rheumatic diseases, syphilis, tuberculo-sis, infection of paranasal bosoms, teeth or tonsils, gonorrhoea, gout, diabetes serve as the reason of iritis. The attack of iritis is shown by pains, reddening, lacrymation and photophobia. At long character of disease sight worsens. When the ciliary body is amazed also, an inflammation name iridocyclitis or to lobbies uveitis. Symptoms of this condition are heavier. The pupil decreases, iris sticks to a crys-talline lens, and the watery moisture grows turbid. Treatment consists in expansion of a pupil by means of atropine and application of sulfanilamides, antibiotics, cortizone etc. Besides, spend treatment of the basic disease which has led to uveitis. Inflammation of a vascular layer often mention also a retina. Thus there are no painful sensations, but the inflammation is dangerous, as sight can in the most various ways be broken. The reason of chori-oiditis is usually tuberculosis or viral infection, hystoplasmosis or tumours.

Inflammatory diseases of a vascular layer are called uveitis. These are heavy enough diseases as they often happen the reason of blindness and considerable easing of sight (approximately in 25 % of all cases of blindness). The number of patients with uveitis during the last years has increased 5 times. Uveitis can be:

anterior: o iritis - An inflammation of iris o Iridotcyclitis - inflammation of iris and of the ciliary body posterior: o Chorioiditis-inflammation of actually vascular layer.

Inflammatory process of all vascular layer is called panuveitis. The retina and an optic nerve can be in-volved into process – neurochoreorhetinitis. Genetically caused defects of immune system, long inflammatory processes in an organism, the centres of a chronic infection, organism easing at chronic diseases and metabolism infringements can be pre-conditions for development of uveitis. Uveitis can sharply proceed, or to be chronic with frequent or rare relapses. The infection gets to a vas-cular layer of an eye at eye wounds, after operations on an eyeball. Often увеиты arise at cornea ulcers. The centres of a chronic or sharp infection in an organism can be an infection source. At suspicion on uveitis the patient should be carefully surveyedInflammatory processes concern anterior uveitis in iris (iritis), iris and a ciliary body (iridocyclitis) and an inflammation only a ciliary body (cyclitis). The patient has complaints to pains in an eye, mor-bidities at eyeball movement, at pressing on an eyeball. Pains amplify at night and can sometimes be very expressed. There can be a photophobia, a frequent blinking. Further sight decrease, a fog before eyes develops. Склера on cornea periphery reddens, colour and colouring of an iris of the eye, a pupil from - 59d for a hypostasis iris changes is narrowed, its reaction to light slowed down. The pupil form can become rough. Are often formed adhesion of iris with a crystalline lens. Sometimes the pupil absolutely grows. In this case the message between eye chambers is broken, outflow of an intraocular liquid is broken, intraocu-lar pressure is thus often lowered. The intraocular liquid can become purulent. All it leads to infringe-ment of a food of a crystalline lens, its turbidity and cataract development. Back uveitis or chorioiditis usually proceed it is erased, it is languid, imperceptible for the patient. Pains in an eye does not happen. At survey of an eye bottom find out the individual or plural centres of the various form and the sizes with inflammatory limbus. The retina is involved into process (retinitis) and an optic nerve disk (papillitis). Chorioiditis is always reflected in sight function. Depending on the location of the inflammatory cen-tres can be found out loss of fields (sites) of sight or if inflammatory process grasps the central part of an eye bottom, there can be a sharp decrease in sight when the patient can distinguish light and dark-ness only.

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Peripheral uveitis are inflammatory processes of a back part of a ciliary body and a peripheral part ad-joining to it chorioidea (back cyclitis, basal uvearetinitis, parsplanitis). Features of this form of uveitis that children and people of young age is more often fall ill and at children illness proceeds especially hard. Thus inflammatory process proceeds imperceptibly, complaints at patients insignificant, at chil-dren they can be absent and the disease is reavealed late, in a stage of complications. Peripheral uveitis it can be accompanied by separation of retina on periphery. In process it is involved vitreous body that can be shown by turbidity vitreous bodies with sharp infringe-ment of visual acuity. Often there is a complicated cataract at which cataract begins with its deep de-partments. Glaucoma occurrence can be one more complication

Visual acuity depends on a transparency of optical environments of the eye providing formation of the accurate image of subjects on a retina, safety of the visually-nervous device of a retina and the spending ways bearing visual impulses in the visual centres of a bark of a brain. If in any of these links there will be pathological changes - result will be this or that degree of decrease in visual acuity.

The cataract causes decrease in visual acuity at the expense of development turbidities in substance of a crystalline lens

The crystalline lens is one of the major components of optical system of the eye which basic func-tion is carrying out of light and focusing of the image of subjects on a retina.

The cataract is the eye disease which basic sign is turbidity of the basic substance or a crystalline lens capsule (decrease in their transparency), accompanied by visual acuity fall.

In a translation from Greek, the word "cataract" means "falling" or "falls". Ancient Greeks be-lieved, that grey colour of a pupil at a cataract represents a film which, like falls, falls from top to down (falls) on a pupil, as a result depriving of the person of sight.

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In a translation from Greek the term the cataract means "falls"

At the expressed turbidity of substance of a crystalline lens the pupil gets grey colourThe cataract is one of the most widespread diseases of an eye. So, according to statistics a fre-

quency of an age-related cataract makes 33 on 1000 population, and this figure essentially increases with the years and reaches in 70-80 years 260 on 1000 at men and 460 on 1000 at women. After the age of 80 years 100 % of the population suffer from cataract. Among a congenital pathology of an eye the cataract also occupies one of in the lead positions.

Prevalence of an age-related cataract in the various countries and world regions essentially differs. It communicates with weight of factors: a racial accessory, character of a food, impurity of environ-ment, potable water structure, district level above sea level, a heredity, etc.

It is very difficult to consider all factors (toxic and beam influence, a trauma, hormonal infringe-ments, etc.), leading to development of the got cataract. In the present review the reasons of develop-ment of an age (senile) cataract as the most widespread, the smaller attention will be given other types of cataracts will be in detail described.Crystalline lens anatomy

The crystalline lens is the major part of optical system of an eye including a cornea, a liquid of an-terior and posterior chambers and vitreous body.

The crystalline lens is located in an eyeball between iris and vitreous body. It looks like a convex lens with refracting force about 20 dioptries. At the adult person diameter of a crystalline lens is made by 9-10 mm, a thickness - from 3,6 to 5 mm, depending on accommodation (the concept of accommo-dation will be considered later). In a crystalline lens one distinguish forward and back surfaces, a line of transition of anterior surface in posterior which is called crystalline lens equator.

The crystalline lens is kept at the expense of fibres supporting it on the place with ligament of Zinn a sheaf attached circular in the field of equator of a crystalline lens on the one hand and to shoots cyliary body body with another. Partially crossing among themselves, fibres are strongly intertwined in a crystalline lens capsule. By means Viger’s sheaf originating from a back pole of a crystalline lens, it is strongly connected with the vitreous body. From different directions the crystalline lens is washed by the watery moisture developed by shoots of cyliary body.

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The supporting device of a crystalline lensWhile examining a crystalline lens under a microscope it is possible to allocate following struc-

tures: a crystalline lens capsule, epithelium of crystalline lens and proper substance of a crystalline lens.

Microscopic structure of a crystalline lens (a crystalline lens in a cut)Crystalline lens capsule. From different directions the crystalline lens is covered by a thin elastic

cover – a capsule. The part of the capsule covering its forward surface, is called as a forward capsule of a crystalline lens; a site of the capsule covering a back surface – a back capsule of a crystalline lens. The thickness of a forward capsule makes 11-15 microns, back – 4-5 microns.

Under a forward capsule of a crystalline lens one layer of cages – epithelium a crystalline lens which is stretched to equator area where cages get more extended form is located. The equatorial zone of a forward capsule is a growth zone (germinative zone) as during all human life from it epithelial cages there are a formation of fibres of a crystalline lens.

The fibres of a crystalline lens located in one plane, are connected by among themselves sticking together substance and form the plates focused in a radial direction. The soldered ends of fibres of the next plates form lenticular seams which, at connection among themselves like orange segments, form so-called lenticular "star" on a forward and back surface of a crystalline lens. The layers of fibres ad-joining a capsule, form its bark, deeper and dense – a crystalline lens nucleus.

Feature of a crystalline lens is absence in it of blood and lymphatic vessels, and also nervous fi-bres. A crystalline lens food is carried out by diffusion or active transport through a capsule of the nu-trients dissolved in an intraocular liquid and oxygen. The crystalline lens consists of specific fibers and water (on a share of last it is necessary about 65 % of weight of a crystalline lens).

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The condition of a transparency of a crystalline lens is defined by feature of its structure and a me-tabolism originality. Safety of a transparency of a crystalline lens is provided with the balanced physi-cal and chemical condition of its fibers and липидов membranes, the maintenance of water and ions, receipt and allocation of products of a metabolism.

The accommodation mechanism. As accommodation understand ability of a human eye equally accurately to see the subjects located both on close, and on far distance. It is provided at the expense of action cyliar muscle and elasticity of a crystalline lens. In a rest condition cyliary muscle is weakened, fibres of cyliary sheaves are tense. Force of a tension through a capsule is transferred to a crystalline lens which thus gets more flat form. It allows to focus on a retina parallel beams from the subjects which are in the distance, providing with that accurate sight afar. At the same time, dispersing beams from close located subjects, cannot be focused on a retina and gather in imaginary focus behind it, therefore in rest of accommodation of the image of close located subjects seem washed away.

Crystalline lens in a condition of rest of accommodation (a) and pressure of accommodation (b)If necessary accurately to consider a subject which is close, there is a reduction cyliary muscles,

fibres cyliary sheaves relax, and a crystalline lens, owing to the elasticity, gets a little more convex form. At the expense of increase in curvature of a surface there is an increase in its optical force. In such condition dispersing beams from the subjects which are close, can be focused on a retina, and im-ages of the subjects which are in the distance, seem washed away.

Crystalline lens in a condition of pressure of accommodation (at the left) and rest of accommodation (on the right)

In a photo at the left images of subjects in the distance seem washed away, and close – accurate (the crystalline lens is in a condition of pressure of accommodation). In a photo on the right a return sit-uation (the crystalline lens is in a condition of rest of accommodation).

Age-related changes of a crystalline lens. Throughout all life there is a change of size, the form, a consistence and a crystalline lens transparency. At the newborn it of practically spherical form, soft, transparent and colourless. With the years the crystalline lens gets the form of a convexo-convex lens, with more flat forward surface and becomes yellowish on colour, completely keeping thus the trans-

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parency. Intensity of a yellow shade increases with the years.Formation of lenticular fibres occurs during all life, however the crystalline lens volume increases

only to certain age. It is connected with consolidation of the central departments of the crystalline lens consisting of older fibres. As a result the nucleus density all time increases: from small and soft эмбрионального nucleuss at the newborn, to accurately differentiated at the adult (by 25-30 years), and then large, turned yellow and sclerosed at the elderly person.

Approximately to 60-year-old age ability to accommodation is lost practically completely. It is connected with consolidation and a sclerosis of a nucleus of a crystalline lens – phakosclerosis. In this connection to the person begins difficult to distinguish accurately the subjects which are at a short dis-tance – after 40 years comes so-called presbiopic age. During this period in connection with infringe-ment of a food of a crystalline lens, delay in it of a metabolism in its various layers initial turbidity may arise.The reasons of development of a cataract

Now all over the world researches of the reasons and mechanisms of development of a cataract (cataractogenesis) are intensively conducted. It is especially actual because the cataract is one of princi-pal causes of reversible blindness. After all to prevent cataract development much easier and more cheaply, rather than for years to spend its conservative treatment, or to carry out expensive surgical in-tervention.

The basic successes in this area are reached in studying of the physical and chemical processes leading to infringement of optical properties of a crystalline lens. At a senile cataract there are changes of a chemical compound of a crystalline lens. In an initial stage of development of a cataract the water maintenance increases, accrues disbalance of some ions, amino acids, the quantity of water-soluble fibers and vitamins, ATP simultaneously decreases. Activity of some the enzymes participating in process of a metabolism in a crystalline lens Besides, decreases, oxygen consumption sharply de-creases, processes of peroxidation of lipids are broken, etc.

Now there are some theories explaining occurrence of turbidities in crystalline lens. However each of them separately cannot explain difficult mechanisms of development of a cataract completely. Most likely, formation age turbidities in a crystalline lens is result of complex influence both internal (en-dogenous), and external (exogenous) factors. Now a principal cause of formation of a cataract is the mechanism of is free-radical oxidation.

Free radicals – the chemical compounds possessing high reactionary ability. In an organism they are constantly formed at a metabolism, however collapse special enzymes and natural antioxidants. Free radicals are very dangerous – they lead to destruction of cellular membranes and finally cause  de-struction of a cage.

In eye fabrics the most essential additional factor stimulating formation of free radicals, light, in particular a short-wave part of a spectrum in a range of 200-300 nanometers is.

As a result of formation of free radicals in a crystalline lens there is a formation and accumulation of the toxic connections leading to irreversible changes of fibers.

Special role the decrease fact in a crystalline lens activity of enzymes antioxidant plays with the years protection and reduction of concentration of natural antioxidants (vitamins A, Е, glutatyon, etc.).Classification of cataracts

All cataracts are subdivided on two basic groups: congenital cataracts and the got cataracts. At congenital cataracts of turbidity in a crystalline lens, as a rule, are limited on the area and do not progress (stationary), the got cataracts have a progressing current.

Because of occurrence (aetiology) the got cataracts share on some groups: Age (senile, senile) cataracts; Traumatic cataracts (arisen as as a result of a stupid trauma (a contusion), and getting wound of

an eyeball); The complicated cataracts (at an inflammation of a vascular layer of an eye (uveitis), short-

sightedness of high degree, a glaucoma, a pigmentary degeneration of a retina and some other diseases of an eye);

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Beam cataracts (connected with damage of a crystalline lens by radiant energy) – infra-red beams (usually professional cataracts – for example, a cataract of glass blowers), x-ray, radiating;

Toxic cataracts (the big number of the "medicinal" cataracts formed as result of collateral action at long reception of some medical products concerns this group also: corticosteroids, antimalarial preparations, amyodarone, etc.);

Cataracts caused by the general diseases of an organism (a diabetes, hypthyreosis, illnesses of a metabolism).

Depending on localization of turbidity in substance of a crystalline lens, a cataract are subdivided into following kinds:

Forward polar cataract; Back polar cataract; fusiform cataract; Layered (zonular) cataract; Nuclear cataract; Cortical cataract; Back subcapsular cataract; Total (full) cataract.

Kinds of cataracts (the crystalline lens in a cut is presented): 1) a layered peripheral cataract; 2) layered (zonular) cataract; 3) forward and back polar cataracts; 4) fuziform cataract; 5) back subcapsular (dish-shaped) cataract; 6) a nuclear cataract; 7) cortical a cataract; 8) a full (total) cataract

On maturity degrees, an age-related cataract divide into four stages: Initial cataract; Unripe cataract; Mature cataract; Overripe cataract.

The cataract usually begins with a crystalline lens bark (cortical cataract), nucleuss (a nuclear cataract) or subcupsular (subcapsular cataract). For an age-related cataract typical localisation of tur-bidities is cortical (92 %). The nuclear cataract meets considerably in smaller percent of cases (7-8 %).

Initial cataract. The earliest signs of a cataract are processes hydratation a crystalline lens – con-gestions in it superfluous quantity of a liquid. This liquid accumulates in cortical layer of the crystalline lens between fibres in conformity with an arrangement of seams. «Water cracks» are formed so-called. Appear characteristic plane turbidity in a bark a little bit later. They are most expressed on crystalline lens periphery, in the field of equator. At transition such turbidities from a lobby on a back surface of a crystalline lens they get the typical form of "equestrians".

Unripe cataract. Gradual progressing of process is reduced to advancement turbidities in a direc-tion of capsules of a crystalline lens and in the central optical zone. If at an initial cataract of turbidity were localised out of an optical zone – in the field of equator – and their presence did not affect visual

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acuity at an unripe cataract the expressed turbidity of substance of a crystalline lens leads to apprecia-ble decrease in visual acuity.

Unripe cataractMature cataract. All area of a bark of a crystalline lens is occupied помутнениями. Sometimes

this stage is subdivided into a stage of almost mature cataract when in a bark are available extensive turbidity, and visual acuity varies in limits from 0,1-0,2 (one – two lines of the table), to the 100-th (the account of fingers at the person) and the mature cataract characterised by full turbidity of substance of a crystalline lens and decrease of visual acuity to level light sense.

Mature cataract with elements of overmaturation.Overripe cataract. The further progressing of a cataract is accompanied by disintegration of

lenticular fibres. Cortical substance of a crystalline lens is diluted, therefore the crystalline lens capsule becomes folded. The bark gets a homogeneous (homogeneous) milky-white shade. More dense nucleus owing to the weight falls from top to bottom. Such crystalline lens reminds a sack. The similar become overripe cataract carries the name Morgani’s cataract.

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Morganian cataract. The brown nucleus of a crystalline lens is displaced from top to bottom.Long-term supervision over a considerable quantity of patients with an age-related cataract have

revealed certain laws in speed of its maturing. The analysis of these supervision has allowed to allocate three variants of progressing of a cataract:

From the occurrence beginning помутнений before development of extensive turbidity in a crystalline lens, demanding operative intervention, passes about 4-6 years. Such fast progressing cataracts meet approximately at 12 % of all patients.

Slowly progressing cataracts developing within 10-15 years and more since time of occurrence of initial changes in a crystalline lens (15 %).

Progressing of a cataract to a condition demanding surgical treatment, occurs within 6-10 years (about 70 %). Clinical displays of a cataract

Complaints to feeling of doubling of subjects, occurrence of "front sights" or stains before eyes, a yellowish shade of the visible image, difficulty at the reading, connected with contrast infringement be-tween letters and the general background can be one of first signs (symptoms) of disease. Visual acuity at an early stage of a cataract practically does not suffer. Duration of an initial stage can proceed from 1-3 till 10-15 years.

At cataract maturing described above the complaint gradually progress, the patient starts to mark visual acuity decrease. In a stage of a mature cataract subject sight is lost, remains only light sense.

Visual acuity and field of vision changes at expressed in turbidities of crystalline lens nucleusDepending on primary localisation of turbidities in a crystalline lens, the clinical picture of a

cataract can have some features.At a nuclear cataract visual acuity afar originally suffers, subjects see as in a fog. In the afternoon,

at a bright sunlight, the pupil is narrowed also quantity of light getting through muddy central depart -ments of a crystalline lens, becomes insufficient. On the contrary, during evening and twilight time, as a result of increase in the sizes of a pupil and, hence, quantity of light which is passing through re-

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mained still transparent sites of a crystalline lens, brightness of the visible image amplifies. Such patients see in twilight light is much better.

Nuclear cataractAt localisation помутнений in a bark (cortical cataract) at initial stages of process visual acuity

practically does not suffer. Such cataracts are characterised by slower progressing.Back subcapsular cataract is often enough shown by fast progressing course and accompanied by

loss of subject sight within several months.Cataract diagnostics

Inspection of the patient with a cataract is far uneasy problem. In the presence of expressed tur-bidities in a crystalline lens, very difficult, and at times it is simply impossible to carry out condition re-search vitreous bodies and retinas standard methods of ophthalmologic inspection. In this connection it is required carrying out of some additional, specialised methods of research.

Thus, all process of inspection of the patient with a cataract can be divided into following methods of research:

Standard (routine) methods of ophthalmologic inspection Visual acuity definition (visiometria) Research of fields of vision (perimetria) Measurement of intraocular pressure (tonometria) Research of a forward piece eyes (biomicroscopy) Survey of an eye bottom (ophthalmoscopia) Research entopic phenomena Additional (special) methods of the research, which performance is obligatory for each patient Refractometria Ophthalmometria Definition of an eyeball frontback axis (ultrasonic scanning in the A-mode) Electrophysiological methods of research (a threshold of electric sensitivity, lability of an optic

nerve, critical frequency of merge of flashings) The additional (special) methods of research which are carried out under indications Ultrasonic in the B-mode Ultrasonic biomicroscopy Densitometria Endothelial biomicroscopy Laboratory methods of research (within the limits of preparation for hospitalisation)

The first group included methods of standard ophthalmologic inspection. The special attention is given to biomicroscopy – researches of an eyeball by means of the special device – a slot-hole lamp. The slot-hole lamp – some kind of a microscope also is one of the basic tools of the ophthalmologist. This device allows to receive an optical cut of a crystalline lens, in details and under the big increase to investigate its structure, to define primary localisation and extent помутнений, to estimate a disposi-tion (displacement) of a crystalline lens.

Certain value has research entopic phenomena (for example, mechanophosphen, a phenomenon of

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autoophthalmoscopy, etc.). These simple methods allow to judge presumably safety retinal neurorecep-tor device at expressed turbidities in a crystalline lens, excluding possibility of survey of an eye bottom.

The second group included the methods necessary for calculation of force of an artificial crys-talline lens (intraocular lenses, IOL). There are special formulas for calculation of force of IOL, as ini-tial data in which it is necessary to enter indicators офтальмометрии (the research, allowing to define refracting force of a cornea) and anteroposterior axis.

The third group – the methods appointed by ophtalmosurgeon under indications, necessary for a choice of this or that technics of operation, type of IOL etc. ultrasonic in the V-mode is applied, basi-cally, at expressed turbidities in a crystalline lens and vitreous body for diagnostics and localisation of structural changes in an eye cavity, and also definition of their character and prevalence.

Laboratory methods of research are appointed, as a rule, before hospitalisation. They include the general analysis of blood and urine, the biochemical analysis of blood, blood research on a HIV, a syphilis, hepatitises In and With, the roentgenogram of bodies of a thorax and additional bosoms of a nose. The conclusions of the therapist, the stomatologist, the ENT-doctor, under indications – other ex-perts (endocrinologist, the nephrologist, etc.) are besides, necessary. All it becomes for the purpose of revealing of contra-indications to operation (decompensation of the general illness, revealing and sani-tation of the centres of a chronic infection) which can complicate a current of the postoperative period.

Conservative treatment of a cataractFrom history of conservative therapy of a cataract

Attempts of treatment of a cataract by the conservative were by undertaken in an extreme antiq-uity. So, Egyptians (about 1650 BC) applied to these purposes compresses from antimony and honey, honey, wine, vinegar, milk, alkali, blood of various animals, and also emetic and a depletive. The great-est doctor of antiquity Hippocrates applied dieto - and physiotherapy (baths, massage, cauterisation of temples), and also various lotions and ointments. In the Middle Ages for cataract treatment recom-mended also althea, a saffron, a carnation, a nutmeg, a coco, castor oil and other means. In 20-30th years of last century for cataract therapy drops Kalium Iodide were widely used. Since 30th years, for treatment of an age-related cataract vitamin preparations which structure includes vitamins A, With, groups In and nicotinic acid began to be used actively.

Modern conservative therapy of a cataractTreatment of initial stages of an age-related cataract is based on application of various eye drops:

Quinax, Oftan-Catachrom, Sencatalin, Vitajodurol, Vitafacol, Vicein, Taufon, Smirnov’s drops etc.The preparations used for conservative treatment of a cataract

However at once it would be desirable to notice, that application of means of conservative therapy does not conduct to рассасыванию already available помутнений in a crystalline lens (in insignificant degree it is property it is marked only at квинакса), and slows down their progressing some.

The basic problem of conservative treatment of a cataract is connected with insufficient clearness of the reason of its occurrence. Therefore the so-called replaceable therapy is applied to conservative treatment, consisting that substances with which lack cataract development communicates are entered into an eye as a part of drops.

As a part of numerous drops from cataract progressing vitamins (In 2, With, РР), Kalii iodidi, an-tioxidants (glutathyon, cytochrome "C"), amino acids, АТP and a number of other substances.

The action mechanism квинакса differs from other drops a little: the preparation promotes resorp-tion of opaque fibers of a crystalline lens at the expense of activating influence on proteolytic (splitting fibers) the enzymes containing in a watery moisture of the forward chamber.

Usually with an initial cataract preparations for cataract treatment are recommended to the patient for long application (years) at various frequency of dropping (from 2-3 to 4-5 times within day).Surgical treatment of a cataractFrom history of surgery of a cataract

Operation on removal of a muddy crystalline lens – extraction of cataracts – one of the most an-

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cient operations.Mentions of the turbidity developing in an eyeball, meet in Old Indian medicine for thousand

years B.C. Extraction of cataracts testify to operation carrying out monuments of Ancient Assyria and Egypt. At excavation of settlements of the Ancient Greece and Rome tools which doctors for cataract removal used are found. The cataract surgery practised in Mark Avrelija's board about what there are mentions in managements of great doctors of an antiquity – Celsus and Galen. In Rome cataract extrac-tions spent by means of one sharp tool, the Indian doctors applied a little bit other technics, using two tools – a needle and spatula.

In an antiquity so-called operation reclination of the crystalline lens was applied. The essence of this manipulation consisted in destruction of the supporting device of a crystalline lens (Zynn sheaves) on the big extent. The muddy crystalline lens, owing to the weight fell from top to bottom, access of light in an eye was thus restored and the patient started to see. Only about half of similar operations were successful – in other cases of eyes it is blind owing to development of the phenomena of an in-flammation and other complications.

About restoration of subject sight after such operation could not be and speech (the patient saw only light) as had was nothing to compensate the lost optical force of a crystalline lens (nearby 20 дптр.). At that time ways of correction aphakia (a condition characterised by absence of a crystalline lens) were not still known.

In 1705 Frenchman Birsso to the first has proved, that the cataract is cataract, and in 1748 Jacque Daviel has described technics of removal of a muddy crystalline lens. The history of modern surgery of a cataract from now on originates.Indications to surgical treatment of a cataract

Now for operation carrying out at a cataract there is no necessity to wait its maturing is a popular belief! It is a lot of years back, at dawn катарактальной surgery, removal of the grown turbid crys-talline lens was carried out only at a full maturity of a cataract. It has been dictated by that the high-grade removal of lenticular weights necessary for the best functional effect of operation and preventive maintenance of its many complications was possible to carry out only at a mature cataract.

Last decades, in connection with introduction of set of modern technologies, updatings of a tech-nique of operation, improvement of microsurgical toolkit, the question on indications to operation has been essentially reconsidered. At modern possibilities of microsurgery of an eye, universal transition to technology of phakoemulsification, there was possible an operation carrying out extraction of cataract almost without complications. All above-stated promoted essential expansion of indications to surgical treatment of a cataract.

Now operation can be spent at visual acuity 0,1-0,2 (on occasion visual acuity can be and above if it is necessary for professional work preservation).

Indications to operation can be divided on medical and is professional-household.Medical indications concern:

Overripe cataract; Bulking up cataract (this situation can lead to closing of a current of a watery moisture through

a pupil in the forward chamber and cause an attack phacotopic (i.e., connected with change of position of a crystalline lens) glaucomas);

Dislocation or crystalline lens incomplete dislocation; Development of a secondary glaucoma (so-called факолитической a glaucoma connected with

reaction to disintegration of substance of a crystalline lens); Necessity of research of an eye bottom at the accompanying diseases demanding treatment un-

der the control офтальмоскопии (a technique of survey of an eye bottom) or laser methods of treat-ment (for example, retinal detachment, changes of an eye bottom at a diabetes, etc.);

Is professional-household indications to operation are defined mainly by visual acuity, a field of vision and safety of binocular sight (volume, three-dimensional sight two eyes), necessary for the pa-tient in a life or in connection with its professional work.

Thus, indications to operative treatment from the is professional-household point of view should be differentiated. So, for example, at the driver of a vehicle, the watch-maker, the seamstress operation

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can be executed at visual acuity 0,4-0,5, and at the patient who does not have necessity to perform thin work at a short distance, operation carrying out is quite possible at decrease in visual acuity to 0,1-0,2.

At a unilateral cataract and high visual acuity of the second eye the question on operation carrying out dares first of all, proceeding from professional and household requirements for high quality of sight (visual acuity and safety of binocular sight).

At a bilateral cataract the eye with lower visual acuity operates in the beginning.Modern surgery of a cataract

Removal of the grown turbid crystalline lens (operation of extraction of cataract) is "pearl" of modern microsurgery of an eye. At today's level of the development the cataract surgery left on qualita-tively new stage which is characterised by wide use so-called «power methods» (uses for the purpose of crushing of a crystalline lens of energy of ultrasound or the laser).

Now there are some kinds of operations of removal of a crystalline lens: Extracapsular cataract extraction Intracapsular cataract extraction Ultrasonic phakoemulsification Laser surgery of a cataract (laser phakoemulsification)

Let's dwell upon each of them.At extracapsular extraction cataracts removal of a nucleus of a crystalline lens and lenticular

weights with preservation in an eye of a back capsule of a crystalline lens is made. It is advantage of operation as presence of a back capsule of a crystalline lens provides safety of a barrier between a cav-ity vitreous bodies and a forward piece of an eye. A shortcoming of the extracapsular extraction of cataract is excessive tramuatization – necessity of performance of the big cut of a cornea and suture.

Operation consists of following basic stages: Preparation for operation (preoperative and it is direct on an operational table: dropping disin-

fecting drops and expanding a pupil, anaesthesia (local injections and intravenous introduction of medi-cal products), processing of an operational field)

Performance of a cut of a cornea Opening and the subsequent removal of a forward capsule of a crystalline lens Removal of a nucleus of a crystalline lens (at the big nucleus in the sizes expansion of a cut or

application various the technician of crushing of a nucleus can be demanded) Clearing capsular bag from the rests of lenticular weights Installation in the capsular bag of an artificial crystalline lens (IOL) Cut hermetic sealing

About a current of the postoperative period and complications of surgery of a cataract it will be told more low.

Extracapsular extraction of cataract now enough widespread, however it is gradually superseded by more modern technique of phakoemulsification.

Intracapsular extraction of cataract consists at a distance a crystalline lens in a capsule through the big cut. Operation is spent by means of the special device, cryoextractor, by freezing a crystalline lens together with a capsule to a device tip. Now this technique practically is not used owing to considerable traumatization of an eye.

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Intracapsular extraction of cataract. The crystalline lens is «frozen» by cryoprobe () also is deduced through a cut (b).

Last decade the actual standard of surgery of a cataract became ultrasonic phakoemulsification, for the first time applied Kelman in the early seventies last century.The method principle consists that through the minimum cut (usually about 3 mm) in the anterior chamber the tip of the ultrasonic device – phakoemulsificator is entered http://www.stolyarenko.com/smi.pub/1981.12.18/. Under the influence of ultrasonic fluctuations there is a crushing of substance of a crystalline lens to a condition of emul -sion. Then, on system of tubes, lenticular weights are deduced from an eye.

One of the main damaging factors during operation is influence of ultrasonic energy on intraocular structures and back epithelium of corneas. Degree of damaging effect that more than is more capacity and time of influence of ultrasound.

Constant perfection of technics of operation, promoted occurrence of numerous new techniques phakoemulsification which application allows to minimise an operational trauma, having reduced an ul-trasound operating time (so to reduce its damaging influence by eye structures) to receive higher func-tional results and the quiet, not complicated current of the postoperative period.

The basic stages of phakoemulsification: The key moments of preoperative preparation do not differ from those at extracapsular extrac-

tion of cataract. It would be desirable to notice, that now phakoemulsification aspire to spend under lo-cal (drop) anaesthesia, keeping contact to the patient throughout all operation.

Performance of an operational cut which can be purely corneal, limbal (it is spent in a zone of transition of a transparent cornea in opaque склеру) and scleral (sclero-corneal tunnel cut). The width of a cut usually fluctuates within 3,2 mm.

Continuous circular capsulorexis – creation by means of special surgical method of a circular aperture in a forward capsule of a crystalline lens.

Hydrosection – some kind of "rocking" of a crystalline lens in a capsule – it is reached by intro-duction in space between a crystalline lens and its capsule of a stream of a liquid. This manipulation fa-cilitates the subsequent crushing of a crystalline lens and allows the surgeon to move if necessary it in a capsule.

Removal of residual lenticular weights Cut hermetic sealing

Nucleus crushing. At this stage occurs actually emulsification – crushing of a crystalline lens by energy of ultrasound. Usually the nucleus breaks into some fragments which then aspirated (are sucked away) from an eye by means of system aspiration.

Stages of crushing and removal of a nucleus of a crystalline lensRemoval of residual lenticular masses. It is carried out by means of simultaneous action of system

irrigation (liquid givings in an eye) and aspiration. At the same stage "polishing" of a back capsule and an equatorial zone of a crystalline lens for the purpose of probably full removal epithelial crystalline lens cells is carried out. This manipulation is performed for preventive maintenance of late complica-tion of operation – formations of a secondary cataract (see further).

Implantation of a flexible artificial crystalline lens (IOL).

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Stages of implantation of a flexible (elastic) artificial crystalline lensCut hermetic sealing (suture is not supposed). If during operation the rigid crystalline lens is im-

planted or for any other reason expansion of an initial cut was required, operation can end with suture.Laser surgery of a cataract (laser phakoemulsification)

Last 20 years some technologies laser extraction the cataracts, the various types of lasers are of-fered. For cataract surgeries it has appeared that the most comprehensible is Nd:YAG the laser on length of a wave 1,44 microns and use of fiber-optical system of delivery of radiation in an eye. On the basis of this laser the domestic system for laser surgery of a cataract is created unique, not having ana-logues in the world.

One of contra-indications to carrying out ultrasonic phakoemulsification is the cataract with a dense brown nucleus. It is connected by that effective crushing of such nucleus can be realizable only at ultrasound use on the maximum capacity and during enough long time interval. Similar influence cannot be carried out without a considerable trauma of intraocular structures and back epithelium of corneas.

Unlike ultrasonic phakoemulsification, use of system on the basis of the laser allows to spend safely crushing of cataracts with nucleuss of the maximum degree of hardness for a short time interval and not causing thus a considerable trauma back epithelium of corneas.Complications of surgery of a cataract

Operation of cataracts extraction executed by the skilled surgeon, represents simple, fast and safe operation. Nevertheless, it does not exclude possibility of development of some complications.

All complications of surgery of a cataract can be divided on intraoperative (events during opera-tion) and postoperative. The last, in their own turn, depending on occurrence terms, are subdivided on early and late. Frequency of development of postoperative complications makes no more than 1-1,5 % of cases.Early postoperative complications:

Inflammatory reaction (uveitis, iridocyclitis), Hemorrhage in the forward chamber, Lifting of intraocular pressure, Displacement (decentralization, disposition) an artificial crystalline lens, Separation of retina.

Inflammatory reaction is response of an eye to an operational trauma. In all cases preventive main-tenance of this complication begin at the closing stages of operation with introduction of steroid prepa-rations and antibiotics of a wide spectrum of action under conjunctiva.

At not complicated current of the postoperative period against anti-inflammatory therapy symp-toms of response to surgical intervention disappear in 2-3 days: the cornea transparency, function of iris is completely restored, there is possible a carrying out ophthalmoscipy (the picture of an eye bottom be-comes accurate).

Hemorrhage in the forward chamber – the rare complication connected with a direct trauma радужки during operation or traumatisation by its basic elements of an artificial crystalline lens. As a rule, against spent treatment blood resolves for some days. At an inefficiency of conservative therapy repeated intervention is spent: washing of the forward chamber, if necessary additional fixing of a crys-

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talline lens.Lifting of intraocular pressure in the early postoperative period can be connected with the several

reasons: "contamination" of drainage system viscoelastics (the special viscous preparations used at all stages of operation for the purpose of protection of intraocular structures, first of all corneas) at their in-complete washing away from an eye; products of inflammatory reaction or particles of substance of a crystalline lens; development of the iridal block. At lifting of intraocular pressure the thaw appoints dropping, treatment with which usually happens effective. Additional operation - a puncture (puncture) of the forward chamber and its washing in rare instances is required.

Infringement of correct position of an optical part of an artificial crystalline lens can negatively af-fect functions of the operated eye. In displacement IOL result its wrong fixing in capsule bag, and also disproportion of size capsule bag and the sizes of basic elements of a crystalline lens.

At insignificant displacement (decentration) of lenses at patients appear complaints to fast fatigue after visual loadings, quite often there is a doubling at a sight afar, there can be complaints to unpleas-ant sensations in an eye. Complaints, as a rule, not constants also disappear after rest. At considerable displacement of IOL (0,7 1 mm) patients feel constant visual discomfort, there is a doubling mainly at a sight afar. The sparing mode of visual work does not give effect. At development of similar complaints the repeated surgical intervention consisting in correction of position IOL is required.

Crystalline lens disposition – full displacement of IOL or backwards, into the cavity of vitreous body, or forwards, into the forward chamber. It is heavy complication. Treatment consists of carrying out vitrectomy, lifting of a crystalline lens from an eye bottom and its repeated fixing. At lens displace-ment forwards manipulation is more simple – repeated placement of IOL in the back chamber from possible it suture fixing.

Separation of retina. Contributing factors: short-sightedness, complications during operation, an eye trauma in the postoperative period. Treatment more often surgical (sealing operation sclere silicone sponge or vitrectomy). At local (small on the area) separation carrying out delimiting lasercoagulation of the retinal rupture is possible.Late postoperative complications

Hypostasis of the central area of a retina (Irvin-Gass syndrome), Secondary cataract.

Retina hypostasis of macular area – one of complications at interventions on a forward segment of an eye. Frequency of occurrence of macular hypostasis after phakoemulsification it is essential more low, than after traditional extracapsular extraction of cataract. More often this complication arises in terms from 4 till 12 weeks after operation.

The risk of development macular hypostasis raises at presence in the past of a trauma of an eye, and also at patients with a glaucoma, a diabetes, an inflammation of a vascular layer of an eye, etc.

The secondary cataract - is widespread enough, late complication of surgery of a cataract. The reason of formation of a secondary cataract consists in the following: remained not removed during cage operation epithelium a crystalline lens will be transformed to lenticular fibres (how it occurs in the course of crystalline lens growth). However these fibres are functionally and structurally defective, the wrong form, not transparent (so-called cells-spheres of Adamjuk-Elshnig). At their migration turbidity, a film which reduces (sometimes rather considerably) visual acuity is formed of a growth zone (equator area) in the central optical zone. Besides, visual acuity decrease can be caused natural process fibrose capsules of the crystalline lens occurring after a while after operation.Secondary cataract. In capsule bag there is an artificial crystalline lens. On a back capsule numerous spheres of Elshing.

Special receptions are applied to preventive maintenance of formation of a secondary cataract: "polishing" of a capsule of a crystalline lens for the purpose of as much as possible full removal of cages, choice IOL of special designs and many other things.

The secondary cataract can be generated in terms from several months till several years after oper-ation. Treatment consists in carrying out posterior capsulotomy – aperture creations in a back capsule of a crystalline lens. Carrying out of this manipulation releases the central optical zone from turbidities, allows rays of light to get freely in an eye, considerably raises visual acuity.

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Capsulotomy can be spent by mechanical removal of a film by the surgical tool, or by means of the laser. Last way is more preferable, as is not accompanied by introduction of the tool in an eye.

"Window" in a back capsule of a crystalline lens after carrying out IAG-LASER capsulotomyHowever the laser method of treatment of a secondary cataract (IAG-LASER capsulotomy) has

also a number of lacks, key of which is possibility of damage radiation of the laser of an optical part of an artificial crystalline lens. Besides, to carrying out of laser procedure there is a number of accurate contra-indications.

Both surgical, and laser капсулотомия – the manipulation spent in out-patient conditions. Re-moval of a secondary cataract – the procedure allowing for some minutes to return the patient high vis -ual acuity under condition of safety nejro-retseptornogo of the device of a retina and an optic nerve.Recommendations for patients with cataract (the postoperative period)Eye drops

As a rule, after the performed operation the surgeon appoints dropping several preparations: disin-fectant drops (for example, «Vitabact», «Furacilline», etc.), anti-inflammatory drops (for example, «Naclof», «Diclof», «Indokollir») and the mixed preparations (contain an antibiotic and dexamethasone which possesses the expressed anti-inflammatory activity – for example, «Maxitrol», «Tobradex», etc.). Usually drops are prescribed by the decreasing scheme: the one should instillate the first week – 4 times, 2nd week – 3 times, 3rd week – 2 times , 4th week – one time, then – cancellation of instillation.

Dropping eye drops it is necessary to accelerate processes of healing and to prevent danger of in-fection of the operated eye.

At dropping a thaw, incline a head back or lay down on a back. Delay a lower eyelid from top to bottom. Drip 1–2 drops from a bottle for a lower eyelid and close eyes. You also can press slightly an index finger (through a sterile napkin) an internal corner of an eye to avoid fast flowing out of drops and to promote the best absorbtion of a drug. If to you some kinds of drops, an interval between drop-ping them are prescribed should make not less than 3-5 minutes. To avoid infection during putting the drops try not to touch with a pipette an eye.The new pedagogic technology used at this lesson: “Black box”, “Web-Net”

The “Black box” method.

It provides the interconnected activity and active participation of every student, the tutor (teacher) in-volves the whole group in this activity.Every student pulls out a card from the box. In the card there are writer in short complaints and clinical manifestations of a disease (variants are given)Students should determine this preparation; give their answer in details and groud it.

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To think over the answer it is given 3 minutes. Then the answer is discussed and additional information on clinical characteristics and ways of the disease are given. At the end of this part of classes teacher comments the answers (its correctness, grounded and level of the students’ activity)This method helps to improve the students’ speech; to obtain the vases of critical thinking as the stu-dents are taught to advocate their opinion, analyze answers given by their group-mates participated in the competition.Variants of cards:1. Diagnosing a disease: acute iridocyclitisTreatment: midriatics, antiinflammation therapy antibiotics therapy. 2. Diagnosing a disease: mature age related cataract3. Treatment: surgery (EEK+IOL)

USE THE METHOD "WEB"

Steps:

1. First, students are given some time for composing questions to the studied theme.2. The participants sit in a circle3. One of the participants who is given a clew puts his question ( he should know the detailed an-swer to it) and holding the end of the thereoat passes the clew 4. A student who has received the clew must answer this question ( the student who has put the question should comment the given answer) and passes the clew to some other student. The participants must go on with asking and answering the questions until all of them are involved in the web.5. As soon as every student has put his question, the last participant who keeps the clew should re-turn it to the previous one who put him a question and son. The game continues until the “web” is “un-failed”: completely. Note: students should be warned to listen attentively to every answer because they don’t know who will be the next.

6.2. Analytical partSituational problems:

1. At the patient after экстракции cataracts gradual decrease in sight is marked. In passing light - a dim reflex from an eye bottom, at lateral illumination a non-uniform grey-white film. Establish the diagnosis. Research methods. The answer. A secondary cataract, biomicroscopy, ophthalmoscopeия.2. The patient of 65 years has addressed with complaints to gradual decrease in visual acuity afar. At survey in both eyes visual acuity 0,01 not коррегирует, pupils of grey colour, a reflex from an eye bot-tom are not present, ВГД (intraocular pressure) in norm.The preliminary diagnosis. The most informative method for diagnosis statement.The answer. An age mature cataract, biomicroscopy.3. The patient of 40 years. In half a year after a stupid trauma of the right eye has noticed absence of subject sight. At survey of eyes it is quiet, the pupil of grey colour, a crystalline lens is grown turbid in all layers, visual acuity - светоощущение with a correct projection. The left eye is healthy. The prospective diagnosis. The most rational way of correction афакии in data cases. The answer. A posttraumatic cataract, the most rational way of correction афакии in data cases correc-

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tion ИОЛ. 4. The patient of 40 years. Complaints to sudden pains in the right eye, a photophobia, слезотечение, sight deterioration. At survey the mixed injection of vessels, on a back surface of a cornea преципитаты, радужка отечна is changed in colour, a relief, drawing, the pupil is narrowed, the wrong form. Ревмопробы the positive.The prospective diagnosis. Complications. The answer. Rheumatic иридоциклит, the secondary glaucoma, the complicated cataract, turbidity стекловидного bodies.

6.3. A practical part1. Eye external examination at lateral illumination.The purpose: eye External examination at lateral illumination.Carried out stages (steps):

№ The answer maintenance

Points

Answer is complete

Answer is not com-

pleteNo answer

1 A desk lamp; magnifying glass of 130 D-are required.

10 5 0

2 A desk lamp is to be adjusted at the lateral side and a little bit in front of the patient; a magnifying glass must be kept between the patient’s eye and the light source.

30 15 0

3 This method is used to concentrate light beams at the examined object, thus allowing to see distinctly the anterior part of the eye.

30 15 0

4 This method is used to examine the skin and mucosa of eyelids, lashes, lacrimal areas, eyeball conjunctiva, cornea, limb, sclera, anterior chamber of an eye, iris, pupil and its reaction, lens.

30 15 0

Total 100 points

2. Measurement of intraocular pressure by palpation.The purpose: measurement of intraocular pressure.Carried out stages (steps):

№

Content of answer Points

Answer is complete

Answer is not com-

pleteNo answer

1To ask the patient to close his (her) eye and look downwards.

20 10 0

2Determination of the intraocular pressure by palpation is made by pressing alternately eyeballs with index fingers of both hands.

20 10 0

3If there is noted weak fluctuance the in-

20 10 0

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traocular pressure (IP) is considered to be normal.

4If there is no fluctuation, the IP is consid-ered to be high (from Т+1 to Т+3).

20 10 0

5 If palpation demonstrates mobile fluctu-ance and fingers co;;apse into an eye, it means that the IP is low (from Т-1 to Т=3).

20 10 0

Total 100 points

7. Forms of the control of knowledge, skills and abilities - The oral; - The written;

- The decision of situational problems;- Demonstration of the mastered practical skills.

8. Criteria of an estimation of the current control№ Progress

In (%)

Estimation Level of knowledge of students

1

.

86-100 Perfectly «5» Sums up and makes of the decision

Creatively thinks

Independently analyzes and explains

Puts into practice

Understands a theme essence

Knows, confidently tells

Has exact idea

2

.

71-85 Well

«4»

Independently analyzes and explains

Puts into practice

Understands a theme essence

Knows, confidently tells

Has exact idea

3

.

55-70 Well

«3»

Understands a theme essence

Knows, confidently tells

Has exact idea

4

.

0 -54 Unsatisfactorily

«2»

Has no exact representation

Does not know

9. Chronological card of employment

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№ Employment stages Employment forms DurationIn minute

2701 Parenthesis of the teacher (theme substantiation) 52 Discussion of a theme of practical employment,

use of new pedagogical technologies (small groups, discussions, situational problems, «a method of snowballs», a round table, etc.), and also check of initial knowledge of students, use of visual aids (slides, audio, cartridge video, models, phantoms, an electrocardiogram, the roentgenogram, etc.)

Interrogation, explanation 50

3 Discussion summarising 254 Granting to students of the task for performance

of a practical part of employment. A summer residence of an explanation and the note for problem performance. Independent курация.

30

5 Mastering of practical skills by the student by means of the teacher (курация the thematic pa-tient)

The case record, business games clinical situational problems

60

6 The analysis of results of laboratory, tool re-searches of the thematic patient, differential di-agnostics, treatment and improvement schedul-ing, выписывание recipes etc.

Work with clinical laboratory tools

60

7 Discussion of degree of achievement of the pur-pose of employment on the basis of the mastered theoretical knowledge and by results of practical work of the student, and with the account of it an estimation of activity of group.

Oral interrogation, the test, discussions, discussion of re-sults of practical work

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8 The conclusion of the teacher on the given em-ployment. An estimation of knowledge of stu-dents on 100 mark system and its announce-ment. A summer residence of the task to stu-dents on following employment (the complete set of questions)

The information, questions for independent preparation.

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10. Questions1. Vascular layer of an eyeball, structure, blood supply, innervation, functions.2. Iris of the eye, structure, blood supply, innervation, functions.3. Iridocyclitis, classification, clinic, diagnostics, treatment, complications.4. Posttraumatic iridocyclitis, clinic, diagnostics, treatment, complications.5. Chorioiditis, clinic, diagnostics, treatment, complications.6. Structure of a crystalline lens, crystalline lens disease.7. Kinds of cataracts by localisation, aethiology.8. Age related cataracts. A technique of examination of patients.9. Conservative and types of operative treatment of cataracts.10. Bulking up cataract, cataracts at the general diseases.11. The complicated cataracts, ways of correction of a cataract.

11. The literatureThe basic

1. Eroshevskij T.I., Bochkareva A.I. «Eye diseasees», 1989г., 263с.

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2. Hamidova M. H «Куз касалликлари», 1996 й., 334 with.3. Kovalevskij E.I. «Eye diseasees» 1995, 280 with.

4. Feodors С.Н.и other «Eye diseasees» M. 2000г., 125 with.5. Jack J. Kanski./Clinical Ophthalmology. A systematic Approach. Atlas/“Butterworth Heineman”, Oxford, UK 2005 y., 372 with.6.Jack J. Kanski./Clinical Ophthalmology. A systematic Approach./“Butterworth Heineman”, Oxford, UK 2005 y., 404 with.7. Materials of lectures.The additional1. Багиров N.A.problem катарактогенеза (the literature review)//Ophthalmologic журн. – 2000. - №6. – s.98-102. 2. Eye diseasees: the Textbook / Under the editorship of V.G.Kopaevoj – М: "Medicine", 2002. – 560с. 3. Maltsev E.V., Павлюченко K.P.biological of feature and crystalline lens diseases. – Odessa: "Astroprint", 2002. – 448с. 4. Pivin E.A., Sosnovsky V.V. Hirurgija зрачковых membranes of a various aetiology//the oph-thalmology Bulletin – 2004. - №6. – s.43-46. 5. Polunin G. S, Sheremet N.L., Karpova O. E. A cataract. – the medical newspaper. – 2006. - №22. – s.8-9. 6. Rabinovich M.G.Katarakta. – М: "Medicine", 1965. – 172с. 7. Сергиенко N.M.Intraokuljarnaja correction. – Kiev: "Health", 1990. – 126с. 8. Fedorov S.N., Egorov of E.V.error and complications at implantation of an artificial crystalline lens. – М: МНТК «eye Microsurgery», 1992. – 244с. 9. Шкарлова S.I.glaucoma and a cataract. A series «Medicine for you». Rostov н/Д: the Phoenix, 2001. – 192с. 10. Internet data are taken from following sites: www.ophthalmology.ru/articles/120_html, www.nedug.ru/ophthalmology/34art-html www.eyenews.ru/html - 67 , www.helmholthzeyeinstitute.ru/articles/1.2html www.eyeworld.com/ophth.articles/html-89, www.scientific-vision.com/html-ophth

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