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ART.I.-Cyclitis

Inflammation of the cilially body, frequently an extention from neighboring structures (iris and choroid), occurs also idiopathically.

The general symptoms of this affection are-
  1. Considerable hyperemia of the subconjunctival arterie, forming a very bright pericorneal injection.
  2. ciliary pain, especially great sensibility on touching the ciliary region.
  3. Formation of inflammatory products, either as opacities in the anterior part of the vitreous or as hypopyon in the anterior chamber.
The turgescence of the disease tissues soon become the source of disturbance of the circulation in the iris, as is manifest from the swelling of the membrane, although it presents no other inflammatory symptoms than the change of the color which accompanies the venous stasis.

As we unable to see the cialiary body, it is only by touching the ciliary region and by the indirect symptoms and by the indirect symptoms that we can be certain of the diagnosis. But, again, these symptoms (subconjunctival hyperaemia, opacities in vitreous, and hypopyon) are characteristic of cyclitis only when we have carefully excluded every other causes of their production.

  1. Simple or Plastic Cyclitis.-Here the pericorneal injection is vary considerable, and the vessels of the iris are dilated and turtuos. Hence arises a slight discoloration of that membrane, the tissue of which is not otherwise altered.

    The anterior chamber seems deeper, the iris being drawn backwards, especially at its periphery, by the plastic exudation, which forms in the ciliary body at the ciliary attachment of the iris. The papillary field; the pupil is dilated. The venous engorgement may give rise to inflammation of the iris (irido-cyclitis). The inflammation may extend also to the choroid, producing effusion in the vitreous body. These complications, as a rule, pass away with the primary lesion. But they may persist after it has disappeared. This variety of cyclitis is accompanied with very acute ciliary pain.
  2. Serous Cyclitis.-The pericorneal injection in this case is much less pronounce that in the former, and the veins of the iris are not distended and tortuous. The pupil is somewhat dilated, the anterior chamber, at first deeper, becomes shallower, and at the same time there is increase of the intraocular pressure.

    A very characteristic symptom is the rapid formation of very fine opacities in the anterior part of the vitreos humor. Which more or less interfere with vision. The disease is often combined with serous iritis, but, on the other hand, it may speard backward to the choroid and assumes the character of glaucoma.

    © Purulent Cyclitis.-In this variety the pericorneal injection is very great, and thus we find on ophthalmoscopic examination that the veins of the retina are dilated and tortuous.

    The stasis in the choroidal veins, which also exist, cannot be directly seen. At the time, opacities appeare in the vitreous, at first flaky, but ultimately membranous, which account for the visual disturbance from which the patient suffers. A characteristic feature in this disease is in the sudden formation of hypopyon. This disappears and reaccumulates in the course of a few days. The ciliary pain is very great, and increase when the eyeball is touched.

    The disease is apt to become complicated with parenchymatous iritis, or with purulent infiltration of the choroid. Progress and Termination.-The affection may be arrested at any period of the inflammation; the inflammatory symptoms gradually disappearing, and the opacities of the vitreous and hypopyon being absorbed. If, on the other hand, the disease advance, serous cyclitis becomes glaucoma, simple cyclitis becomes purulent, while the surface of the ciliary body, choriod and prosterior portions of the iris are covered with plastic exudations. These exudations become organized, forming false vascular membranes, often of considerable thickness, which produce certain traction on the cilliary insertion of the iris, so that the anterior chamber is deepened at its periphery. The compression and obliteration of the ciliary arteries cause atropy of the iris and choroid, and interfere with the nutrition of the vitreous body, which becomes the seat of organic opacities, and undergoes atrophy; as a consequence of the contraction of its dimensions we have seperation of retina. The lens loses its transparency; and the whole eyeball gradually atrophies, but is liable to periodical inflammation, with severe pain, so that the other eye during these inflammations is affected.

    3. Prognosis.-Cyclitis is always a serious affection. Of the three forms just described, the sereous and purulent in their early stages are least dangerous, at least when the purulent is not caused by a foreign body or a dislocated lens, because in such a case irritation is maintained and resolution of the hyperaemia and inflammation prevented.

    Again, purulent cyclitis is very dangerous if it supervene after an operation- for example, after the extraction of cataract- for it then extends rapidly to the deep structures, and brings about the purulent liquefaction of the entire eye.

    The most serious prognosis is that of plastic cyclitis which has attained a certain degree of development. This affection so greatly disturbs the nutrition of the important structures of the eye that it almost always involves atrophy of the organ.

    Etiology.-Inflammation of the ciliary body may follow an iritis or choroiditis. But the affection is often traumatic, and may then be caused by wounds in the ciliary region, the presence of a foreign body in the eye, or again by the sympathetic action which, in certain circumstances, one inflamed eye exercises on the other. This last form (sympathetic ophtalmia) will be the subject of a separate chapter.

    Treatment. - The great hyperemia, indicated by a bright pericorneal injection, demands antipuphlogistic treatment, atropine and the internal administration of opium. Violent pain and sleeplessness should be checked by morpia or chloral.

    In the plastic and prulent forms we must employ mercurial treatment, administered in the same way as in serious cases of iritis (regular inunction). The serous form should be treated, like serous iritis, with purgatives, diaphoretics (injections of pilocarpine), diuretics and derivatives acting on the skin. If the aqueous humor be muddy, and if there be increase tension of the eye, we must perform paracentesis of the cornea, which should be repeated if necessary, and if the symptoms persist we must have recourse to iridectomy. When purulent cyclitis is the result of an operation- for example, after of cataract by section-the general condition of the patient often does not admit of active antiphlogistic remedies, or any debilitating treatment. Hot compresses, tonics, in certain cases a tight compress and bandage, give the best results. An eye entirely lost by cyclitis and still painful, ought to be enucleated, unless opto-ciliary neurectomy (vide infra) permanently checks pain and inflammation, as we have frequently observed.

    The presence of a foreign body in the eye demands as the first condition of success in extraction. If we do not succeed, the eye is almost always lost, and the only question then is to preserve the other from sympathetic inflammation.

    ART.II.- Lesions of the Ciliary Body.

    Wounds which involve the ciliary are-either clean-cut wounds made with a sharp instrument, or irregular wounds made by foreign bodies (splinters of metal, glass, thorns, etc.). These agents may produce a wound without penetrating the eye, or they may penetrate, or again they must be stopped between the lips of the wound. In this last case they are easily removed by a magnet or forceps, if the foreign body has penetrated the eye, the possibility of surgical interference depends on its special position. (See the remarks on foreign bodies in the lens and vitreous humor.)

    Clean-cut wound of the ciliary region, when they are not very large and not very deep, often heal very rapidly under a compress and bandage. If there be prolapse of the iris or of the ciliary body, the hernia should be snipped off.

    If there be escapes of vitreous, and if the wound be large, it may be necessary to unite it by a suture. To avoid penetrating the eye with needle while suturing, which might happen if the patient were to move suddenly, we use a tread provided with needle are made to pierce the lips of the wound from within outward.

    The chief danger to be feared in a wound involving the ciliarry region is a sympathetic inflammation in the other eye. Tumors of the ciliary body are described with those of the choroid.

    ART. III.-Irido-Choroiditis.

    We must distinguish two varieties of the disease.

    1. In the first the disease begins with iritis, following which, posterior synechiae keep up a chronic inflammation, with extends to the anterior parts of the choroid. In cases of complete posterior sysnechie, the equilibrium of the internal fluids of the eye is interrupted by the stopping up of the communication between the anterior and posterior chambers. The fluids then accumulate behind the iris, driving it towards the cornea; but it can only yield to the pressure at the periphery, the papillary margin being adherent to the lens the pushing for ward of the iris at first only appears at certain places, giving it an indented appearance; later it becomes general.

      The iris in the stages is only tarnished and discolored, but now it is distended and shows symptoms of atrophy. If the pupil be in such a condition as to admit of ophthalmoscopic examination, we find opacities in the anterior part of the vitreous humor, which are fine and filamentous.

      The eyeball is at first hand, but afterwards softens.

      The pain is often insignificant.

      Vision is in the early stage little altered, but later sensibly diminished, owing to opacities in the vitreous, and it decreases in proportion as the nutrition of the choroid is involved.
    2. In the second variety the disease in the choriod, in which membrane Inflammation with its consequence has already produced considerable alternations in the visual acuteness before the iris is affected. Thus we may already have numerous opacities in the vitreous, effusion between the choiroid and retina, disturbance in the nutrition of the lens (albuminoid infiltration), and it is only after these changes that the inflammation extended to the iris, and that plastic exudations form posterior synechie.

      The lens and the iris are now pushed forward towards the cornea, so that the Anterior chamber is almost entirely obliterated; and lastly, the disease presents the same combination of symptoms as has already been describe in the first form.

      When the inflammation has begun in the iris form than in the other, and when it does become opaque it is at a later period. Decrease of visual acuteness is at first inconsiderable, and chiefly depends on deposits of plastic lymph in the pupikl; later there are opacities of the vitreous humor and of the lens.

      In cases in which the inflammation begins in the choroid, there is considerable diminution of vision from the beginning, owing to the formation of capacities in the vitreous humor. Often we have detachment of the retina occurring early in the disease, with its characteristic influence on the visual field. The intraocular tension then perceptibly decrease, the lens becomes opaque, and later undergoes calcareous transformation.

      The iritis complicates the choroiditis does not present any marked inflammatory symptoms, but is insidious in its course. Progress and Termination.-Both forms of irido-choroiditis are generally chronic, and are accompanied with periodical exacerbations of the inflammatory symptoms.

      In the course of the disease, the increase of the internal pressure may bring on glaucomatous symptoms or atrophy of the retina.

      In other cases, an effusion of serum or of blood on the internal surface of the choroid produces separation of the retina, which complication is manifiested by special symptoms, to be explained when we speak the disease of the choroid and retina. S a rule, if the morbid process be not arrested, neoplastic massesn fill the posterior chamber, and the irido-choroiditis, after involving the ciliary body, and giving rise to cyclitis, terminates in atrophy of the eyeball.

      Prognosis.- the prognosis is grave, but varies with the period and special form of the disease.

      In slight cases of irido-choroiditis without any great alternation of the choroid, where there is no compecation of retina or lens, and when the plastic matter behind the iris is not great, judicious treatment may arrest the progress of the disease, maintaining and even improving the state of vision. On this account the prognosis is less grave when the irido-choroiditis has begun with the iris.

      In this form, we must not despair even when atrophy of the eyeball has already begun, if this antrophy entirely depend on nutritive changes in the vitreous, without definite alternation in the tissues, and if the central and peripheral visual perceptions are still tolerably good. Treatment arrests the progress of this atrophy.

      The prognosis becomes absolutely bad when there is separation of the retina, or when the ciliary body is included in the morbid process (as shown by sensibility to touch, peripheral reaction of the iris, etc.).

      Etiology.- the majority of cases of irido-choroiditis originate in posterior synechie formed during an iritis, or in the presence of foreign bodies, e.g., a dislocated lens, which, even although encysted, may become dangerous after the lapse of a longer or shorter period from displacements in the interior of the eye. Again, cases which begin with choroiditis may often be connected with the rheumatic or syphilitic diathesis or alternations in general health, for example in women at the change of life, or in young women from sixteen to twenty in consequence of irregularities of menstruation.

      Treatment.-In every case of irido-choroiditis where there are posterior synechie, it is of the first importance to liberate part of the papillary margin, or to establish the communication between the anterior and posterior chambers by iridectomy.

      Whenever the communication is established the vision improves, the state of the choroid is ameliorated, as is also the nutrition of the vitreous, in which the opacities are gradually absorbed; consequently this re-establishment of the communication between the two chambers should be got at any cost, even should it be necessary to repeat the iridectomy. Once the desire result is obtained, we often see eyes which have already begun to atrophy regain their normal volume and tension.

      This condition does not therefore forbid operation, but it need not be daid that operation may be useless if the atrophy have reached a certain stage and be the result of choroidal atrophy with obliteration of the vessels.

      There are many difficulties in performing iridectomy when false membranes closely connect the posterior surface of the iris with the capsule of the lens and with the ciliary processes. Besides the difficulties of seizing the iris, it is important in such cases to remove at the same time, as far as possible, the neoplastic masses.

      There is besides, in these cases, a very great tendency to occlusion of the opening thus obtained by new plastic effusion. Consequently it is of the greatest importance to be able to remove a large flap of I ris to its very periphery, and along with it the subjacent false membranes.

      In a great number of cases, this result can only be obtained by simultaneously ext racting the lens, which moreover is often found altered in its nutrition and more or less opaque. The ordinary iridectomy, as already describe, only partially answers lur purpose, and the following method should be substitute. The incision is made with von Graefe’s straight knife, such as is used for linear extraction of cataract. We pierce the inferior margin of the cornea, and go behind the iris with the point of the knife; then, carrying it along behind the iris to the point where we wish to make the counter-puncture, we again pierce the iris and cornea, and finish the section.

      This incision resembles the peripheral incision made in the extraction of cataract by von Graefe’s method, with this difference that the knife at the same time cuts the iris at its ciliary insertion, and opens the capsule of the lens, so that as a rule a little lenticular substance escapes by the wound. We then introduce a special form of capsular forceps (Fig. 78) in such a way that one of the blades is placed between the iris and the cornea, and the other behind the iris and false membranes. These latter blades will therefore penetrate the lens itself. Having pushed the forceps firmly forwards, we draw out all that we can take hold of between the blades, and if any resistance is met we must disengage the mass by a few strokes of very finely-bladed scissors (Fig.79).

      Generally this manipulation suffices to produce the simultaneous escape of the lens; if, however, it does not follow the iris and false membranes, the capsule must be torn with the cystitome, and extraction performed in the usual manner (see article on cataract).

      It is of importance also to remove as completely as possible all the great dragging of the iris, to which they adhere. Notwithstanding the removal of a large portion of the false membranes, we often see the opening enclosed by fresh neoplastic formation.

      It then becomes necessary to repeat the operation, but this should nor be attempted till the inflammatory process which produced the false membranes has complete subsided. When the time comes for repeating the operation, if the lens have already been removed, it may suffies to rupture the false membranes with sharp crochet, after the corneal incision, and to remove as much of them as possible. At other times it is better to perform iridotomy, or capsulotomy, or a combination of the two operations (see operation for secondary cataract). Besides, it is necessary to institute constitutional treatment in accordance with the principles already enunciated, and to take into account the special indications furnished by menstrual affection, by the sudden arrest of a hemmorrhoidal discharge of by habitual constipation. Again we have seen good results obtained by the prolonged use of potassium iodide and small doses of corrosive sublimate. Only, we must steadily bear in mind the fact, that no medication can have a salutary influence on the eye until surgical interference has given to the organ the conditions essential for the nutrition of the diseased structure.

    ART.IV.-Sympathetic Ophthalmia.

    When an eye is affected with traumatic irido-choroiditis, we often find that a similar affection springs up in the other eye, and it is this which has received the name of sympathetic opthalmia. It presents it self, however, under various forms.

    1. Sympathetic irido-cyclitis, the most dangerous and most common form, begins with diminution of the visual acuteness, lychrymation, photopobis, and pericorneal injection.

      Comtemporaneously, exudations are formed at the pupillary margin and on the posterior surface of iris. Thes exudations are rapidly organized, and form solid false membranes.

      The pupil is then retrached, and, in consequence of the complete posterior synechia, immobile and insensible to the action of atropine. The iris at first wollen by effusion into its parenchyma, and the anterior chamber is ahallower. Soon to these symptoms are added those cyclitis, sensibility to pressure on the ciliary region, effusions into the vitreous and gradual softening of the eyeball.

      The visual acuteness is now greatly reduced, and the visual field contracted. As the disease progress, the pupil becomes filled with plastic material, the periphery of the iris is drawn backwards by false membranes, which unite it posterior surface with the ciliary body; consequently at the periphery that anterior chamber is increase in depth. The lens grows opaque, the retina becomes detached, and the eyeball atrophies. In the most favorable cases a certain amount of visual perception remains which suitable surgical operations increase.
    2. Sympathetic serous iritis is much less dangerous than the preceding form. Its symptoms are those of serous iritis in general; slight subconjuctival injection, muddiness of the anterior chamber, the grayish deposits on the posterior surface of the cornea, normal appearance of the iris, dilatation of the pupil, and increase of the intraocular pressure.
    3. Sympathetic chorio-retinitis has till now been observed only by von graefe, who has seen two cases. One of the cases fallowed the linear extraction of a calcareous lens, which had fallen into the anterior chamber, with consequent irido-cyclitis and great sensibility to pressure in the eye which had undergone the operation. Six weeks after the operation the patient complained of his other eye, which had fill up till this period been in normal condition; and in it was found a sudden diminution of the acuteness of vision; with a defective visual field.

      On ophtalmoscopic examination the retina was seen to be hazy, and the retinal vein dilated and tortuous. Simultaneously slight symptom of serous iritis appeared.

      Under treatment (Blood-letting, corrosive sublimate, iodide of potassium), and at the same time as the eye operated on ceased to be sensitive, the vision of the sympathetic eye gradually improved, and it regained its normal sight.

      The second case is that opf a person who had lost an eye in youth from separation on the retina, with calcareous deposit in the choroid. At the age of twenty the other eye became affected with the symtoms of retinitis which we have just described, and at the same time the impaired eye became sensitive to pressure. The latter having been enucleated, the phenomena of the sympathetic affection disappeared.
    4. Sympathetic neurosis.- the fourth form of sympathetic affections is distinguished from the other in not being accompanied with any material change in the structure of the eye.

      It has been called sympathetic neurosis, and is characterized by great photophobia, with second spasm of the orbicularris, lachrymation, and slight pericorneal injection, which is present especially after efforts of vision. At the same time there is a want of visual power, and an enfeeblement of the accommodation.

      In addition to the sympathetic affections which we have just indicated, various forms of conjunctivitis, conneitis, choroiditis, etc., have been describe as following traumatic lesions of the other eye. Still, it is scarely accurate to place these affections in the same category with sympathetic disease.

      Progress and Termination.- the time which may elapse between the effection of the first eye and the manifestation of the sympathetic disease in the other, is very variable. If it sometimes supervenes in the course of a few weeks, it has been observed in other cases to occur only after twenty of thirty years, always preceded by the characteristic painful sensibility of the ciliary region of the eye first affected.

      If the sympathetic ophthalmia assume the form of irido-cyclitis, it does not come on suddenly, but follows rather an insidious course resisting all treatement, and gradually destroying vision by producing atrophy of the ball. Yet it sometimes stops spontaneously, leaving a certain amount of luminous perception.

      Sympathetic serous iritis does not expose the vision to serious danger; it is a very mile form of serous iritis, and is easily controlled by treatment.

      Again, sympathetic neuosis, whilst preventing the patient from using his eye, never produces any important alteration in structure.

      Prognosis.- it is very good for neurosis, favorable for serous iritis, very bad for irido-cyclitis, for the cases ase rare in which, notwithstanding active interference, we succeed in preventing any useful amount of vision.

      Etiology.-Sympathetic disease is to be expected when one eye has been injured so as to involve the ciliarry region, either immediately or secondarily, when at a later stage the process of cicatrisation produces a dragging on this region, as, for example, in cases of prolapsed iris being caught in the wound.

      Foreign bodies which have penetrated the eye, even although they remain quiescent for several years, may suddenly become the source of irritation, probably in consequence of small displacements in the interior of the eye. Operations rarely give rise to symphathetic affections of the other eye; they have been seem after extraction of cataract, and after iridodesis.

      Calcareous cataracts or calcareous deposits on the choroid, which occur after irido-choroiditis, or irido-cyclitis, even in atrophic stumps, may keep up a sae of chonic irritation which mat at any moment excite a sympathetic affection in the other eye. The appearanve of the disease in the second eye is often preceded by pain, sometimes very acute, which is always elicited on touching the ciliary region of the eyes fisrt affected. This characteristic symptom tells of imminent danger, or, if the disease has already begun, indicates its true nature.
    The means of transmission of the irritation from one eye to the other are-
    1. The ciliary nerves, some of which may preserve their conductility even in an atrophied eye, the neurilemma and fibrous envelope resisting the degenerative and atrophic process for length of time ( von Graefe).
    2. Much more rarely, the optic nerve (Mooren), and the intravaginal space (Knies) which communicates by the arachnoidal space with the other eye.
    3. The vessels; in a case of sympathetic choroiditis, eiht the ophthalmoscopic appearance of neuroretinitis, the autopsy did not show any other way of transmission (O. Becker).
      4. Micrococci found in the intravaginal space by Snellen and Leber, as well as by Deutschmann, who, after repeated injections of microbes into the eye of a rabbit, established an inflammation of the other one, propagated through the optic nerve and its envelopes, prove the sympathetic ophthalmia can be of an infectious nature.

    Treatment.-the great danger of sympathetic opthalmia, and the impossibility of foreseeing which form in the disease will take, indicate the necessity of anticipation and active intervention, whenever the condition of one eye causes us to fear for the other. This fear may always be entertained when there is pain on touching the ciliary region. The only certain means of preventing the development of sympathetic ophthalmia lies on the injured eyeball. Some cases of sympathetic ophthalmia, in which the disease is already present, and is in the form of irido-cyclitis, the enucleation of the first injured eye is no longer of any avail in arresting the evil, yet it must not be neglected, when there is a foreign body in the eyeball. If the eye be painful to touch and deprived of all vision.

    An eye which is affected with sympathetic irido-cyclitis is rarely influence by the remedies recommended for that disease. Hot fomentation without interruption during 8 to 10 hours daily, energetic application of atropine, mercurial inunctions and diaphoresis, obtained by giving pilocarpine subcutaneously, are the best remedies. On the other hand, experience has shown that any operation is prosuctive of harm.

    At the very beginning of the disease, some have believed that they saw good results from an iridectomy, made with a von Graefe’s linear section knife in the extreme periphery. But we must abstain from all surgical interference if the inflammation has already reached a certain intensity, if the yellowish exudation products fill the pupil, attaching the iris to the capsule, if the iris be furrowed with large vessels, etc. attemps at iridectomy made at this period are not only without benefit, but are very detrimental, because they are a source of new irritation which increase the inflammation, rendering the loss of the rey almost inevitable.

    Thus it is now recognized that we must wait till the inflammatiory symptoms have disappeared, the development of vessels in the iris stopped, the visible false membranes assumed a grayish appearance without vascularity, till the ciliary region has caused to be painfull to the touch, and, finallt, till the tention of the eye, always considerably diminished, does not notably vary from the normal.

    The time necessary to wait as long is from three to four months, but as a rule it is well to wait as long as possible, so that the eye may have regained a state of perfect quiescence. We must not be entrapped into premature interference by the dread of atrophy of the eyeball and loss of vision.

    As soon as all irritation has passed of, we should iridectomy, with extraction of the lens and false irido-retinal membranes, in the manner already described.

    If the papillary opening thus obtained afterwards becomes closed, we should excise another portion of the iris. Perhaps in such cases it would be better to perform iridotomy,which operation shall be described when we speak of secondary cataract. For sympathetic serous iritis, it suffices to use the remedies which have been mentioned for the ordinary form of the disease as soon as the eye which causes the sympathetic affection has been removed.

    The enucleation of the first affected eye always suffices to cure sympathetic neurosis, and it does so almost at once. Following up an idia of von Grafe’s we have employed section of anterior ciliary nerves behind the point where palpation produces acute pains, instead of enucleation, not only in manifest sympathetic neurosis, but in very case where we have entertained fears of a sympathetic affection. The following out a similar idia, section of the ciliary nerves has also been performed in the posterior segment of the eyeball, the wection either leaving out the optic nerve (Snellen), or including it (Boucheron, Schoeler). This letter method is to be preffered, because we are surer of cutting all the ciliarry nerves, and thus there is a greater chance of attaining the desired effect. The operation is performed as follows;

    Having made incision in the conjuctiva along the external border of the cornea, and having detached it freely from the sclerotic, a thread is passed through the anterior extremity of the external rectus muscle, which iscut as in the operation for strabismus. This being done the eyeball is turned as far as possible to the opposite side, and the optic nerve is cut as far behind the eyeball as possible. It becomes then easier to turn the eyeball round so that its posterior pole becomes visible, and we can, without difficulty, cut at first the part of the optic nerve left on the eyeball, and all the ciliary nerves at a centimetre’s distance round the optic nerve. Lastly, the eyeball is replaced in its normal position, the external muscle is attached to its scleral insertion, and the wound of the conjuctiva closed bu sutures. After this we perform the tenotomy of the internal rectus muscle in order to cut the ciliary nerve, which passes under it. We thus pressure bandage is applied.

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