Diseases Of The Iris, Ciliary Body, And Choroid; Sympathetic Inflammation And Irritation.
Diseases Of The Iris, Ciliary Body, And Choroid; Sympathetic Inflammation And IrritationBy ROBERT L. RANDOLPH, M. D.,
OF BALTMORE, MD.
Congenital Anomalies of the Iris. Heterophthalmos is the condition where the irides differ in color. One iris may be brown and the other blue. These differences in color may exist in the same iris, so that one part will have a distinctly different nuance from its immediate surroundings. The pupillary margin of the iris may be quite different in shade from its peripheral portions. Minute areas differing in color are not infrequently seen, and sometimes these areas assume the form of elevations upon the surface of the iris. (See also page 147.)
Persistent pupillary membrane is the remains of the membrane which occupied the pupillary field during fetal life, and, according to Manz, is part of a layer of tissue of the head mesoderm containing vessels and surrounding the secondary ocular vesicle ; this layer becomes differentiated into a posterior portion, the choroid, and an anterior portion, the membrane pupillaris (see also page 23). What is seen of this membrane consists only of a number of fine (usually pigmented) threads, anastomosing with one another and arising from the anterior surface of the iris and near the free border of the latter; in other words, from the circulus iridis minor. The threads are Dever present in ally considerable Dumber, for rarely more than ten or twelve, and usually less, are seen. These threads after converging pass across the posterior chamber and come to a point on the anterior capsule of the lens, this point being frequently marked by a pigment speck, or they may reach the anterior capsule at different points. it is seldom that the threads spring from all sides of the pupil, but usually from one or two points. They do not invariably pass across to the lens capsule, but after running out for quite a distance into the pupillary field they return to the iris to be inserted near their point of origin.
A persistent pupillary membrane is not infrequently confounded with the synechia which remain after an iritis, but the oblique illumination will reveal the true nature of the affection. Moreover, the pupil dilates symmetrically to its full extent in the former condition, while in the latter case irregularities may be seen in the contour of the pupil (Fig. 227).
According to Fuchs, persistent pupillary membrane. is of comparatively frequent occurrence in the new born. Jacob and others' have succeeded in injecting these threads soon after birth, thus showing that the threads are vessels. As is well known, these threads undergo atrophy and are obliterated in the ordinary course of events. This affection is Dot often seen in both eyes.
The disturbance in vision is slight, depending upon the number of threads and the extent to which the anterior capsule is involved. The condition practically never demands operation, though von Graefe resorted to operation where the vision was I/100 Coloboma of the Iris. This is one of the most frequent malformations met with in the eye. It consists of an oval shaped fissure or gap in the iris, which has the effect of prolonging the pupil in a direction usually downward and a little inward. A complete coloboma is where the fissure separates the iris in its entire breadth, and an incomplete coloboma is one where the cleft stops short of the ciliary border of the iris. The coloboma is usually smaller at its ciliarv end, though the reverse of this has been observed quite often, in such cases the borders being almost parallel instead of convergent. There is often seen just within the pupillary end of the fissure a slight con which gives to the pupil and coloboma together the appearance of a keyhole. Sometimes the pupillary ends of the fissure are bridged over by a slender membrane or a thread, forming what has been described as the bridge coloboma. In those cases where a thread has been formed the latter is supposed to be the remains of a pupillary membrane.
Coloboma is generally bilateral, though Manz is of the opinion that the affection is more frequently monolateral. In the latter variety the other eye often exhibits peculiarities, either in the color of the iris or in the shape of the pupil.
The congenital coloboma is distinguished from the artificial coloboma by the presence in the former of the sphincter, while in the latter, i. e. in an artificial coloboma (as after an iridectomy), the sphincter has been excised along the margin of the coloboma.
Coloboma of the iris is due to incomplete closure of the ocular fissure (page 22), and along with this condition coloboma of the choroid often exists, and sometimes the fissure is seen in the ciliary body and lens, and even in the optic nerve and macular region. It is not infrequently associated with microph and cataract (either congenital or acquired), and other fissures which usually close in fetal life may be seen to have persisted, forming harelip and coloboma of the lids.
The direction of the iris coloboma is usually downward and inward, but exceptions to this rule have been observed; for example, the coloboma may be up and in, tip and out, inward, outward, or downward. The accompanying illustration is from a photograph (Fig. 228) of one of the very few cases reported where the coloboma was directed upward. The case was first put on record several years ago by Theobald.'
The possible explanation of the unusual locations for the coloboma is that the ocular vesicle made a quarter or half a revolution about its long axis.
No satisfactory explanation has been offered for the failure of the ocular fissure to close. Some regard it as simply an instance of retarded development, while others think that inflammation must have played a part in producing the defect. The role played by heredity in this affection is certainly worthy of consideration.
Irideremia, or Aniridia. This is a condition in which the iris is either completely absent or in which only one or more segments remain. When the irideremia is complete, it is possible to see the entire lens, which is often so exposed that even when cataract is present there is good sight, there being space enough between the edge of the lens and the ciliary processes for the light to pass through. When the irideremia is incomplete there is an absence of the iris at certain points, so that only a segment remains here and there. The narrow rim of iris which is sometimes seen just behind the corneo scleral junction all the way around is not incomplete irideremia.
Myopia, hyperopia, astigmatism, and amblyopia are often present in irideremia; also a cloudy cornea. Cataract is not infrequently found associated with it, generally in the form of the anterior or posterior polar cataract which in these cases is usually congenital. It should be said, however, that eyes affected with irideremia are peculiarly prone to cataract, so that this Iasi named condition may make its appearance any time after birth.
Irideremia is almost always a binocular affection. As regards its etiology, heredity undoubtedly plays an important role. The affection is clearly One of retarded development.
Under this head should be mentioned those cases where there is a narrow rim of iris springing out all the way around in front of the periphery of the lens. This condition is one step removed from irideremia, and is really an instance of rudimentary development of the iris.
The wearing of dark glasses in irideremia sometimes gives great relief, or spectacles with a stenopaic slit.
Ectopia Pupille (Eccentric Position of the Pupil; Corectopia). The normal situation of the pupil is not exactly in the center of the iris, but a little below and to the inner side of the center. Sometimes the pupil is found eccentrically located. It may be near the normal site, and again it may be remote from this situation, as, for instance, near the ciliary border. Such a pupil is long oval in shape, rarely, if ever, round. The most usual location is downward and inward, though it has been observed upward.
We are completely in the dark as to the origin of ectopia. Some authors believe that the condition is closely allied in its origin to coloboma of the iris, and give as a reason that the misplacement is nearly always at the most frequent location for coloboma. Others hold the opinion that ectopia pupille is due to a lack of development of the muscular elements of the iris at a certain point, with possibly an excessive development of the same elements at a point opposite, the effect being to pull over the pupil to the stronger side.
A not infrequent complication of ectopia pupille is a dislocated lens.
Dyscoria (Faulty Pupil). This is a condition in which the pupil is faulty or irregular in shape, and is usually brought about by the presence of little excrescences on the margin of the pupil. These excrescences may attain such a size as even to, meet at different points in the pupillary field, leaving only here and there small openings a condition called corestenoma congenitum (Von Ammon), also polycoria. The condition is not infrequently seen in horses. The nature of these excrescences is not known.
Motor Disturbances of the Iris. The movements of the iris consist in dilatation and contraction of the pupil, and a motor disturbance of the iris means an affection which is characterized by some alteration in the size of the pupil.
Mydriasis and Myosis. An alteration in the size of the pupil may show itself in either persistent dilatation (mydriasis) or contraction (myosis) of the pupil, or in a condition in which the pupil is incessantly dilating and contracting (see also page 149).
Hippus. This condition is one which is characterized by constant dilatation and contraction of the pupil. It is really a clonic spasm of the sphincter pupille (see also page 151).
Iridodonesis (iris tremulans) is a tremulous movement of the iris whenever the eyeball is moved, and is due to loss of, or defective support of, the iris. The condition is often seen after cataract extraction, especially the simple extraction. It is observed in cases of fluid vitreous where trophic changes have taken place in the lens and the latter has become smaller ; in congenital cataract where the lens has undergone calcareous degeneration and shrinkage; and, finally, in luxation of the lens. Although not a functional motor disturbance of the iris, iridodonesis is conveniently referred to in this place.
Hyperemia of the Iris. Hyperemia of the iris is characterized by a change in the color of the iris, which assumes a yellowish red shade, so that a blue or gray iris appears greenish, and a brown iris will have in it a sugges¬tion of red. In dark eyes, however, this discoloration is not so marked as it is in eyes of the blond type. As a rule, this symptom is more noticeable in cases of hyperemia than in conditions of marked iritis, where the iris is the seat of structural changes, and where the aqueous humor is filled with the products of the inflammation. De Weaker remarks upon the frequency with which a similar discoloration of the iris occurs in severe subconjunctival hemorrhages, and he thinks that in such cases it is due to the fact that either the iris or the aqueous humor has become infiltrated with the soluble coloring matter in the blood.
In cases of chronic hyperemia there is a discoloration of the iris due to changes in the pigment cells, and a complete disappearance of the pigment at the pupillary border, which becomes ragged and notched. These changes are only seen after the Hyperemia has existed for a long time. The same appearance of the iris is seen in very old people without coincident hyperemia, and is attributable to senile changes in the iris.
In hyperemia of the iris the pupil no longer reacts as it does normally, but remains more or less contracted ; and this sluggishness of' the pupil is even noticeable when atropin is used, several instillations of the mydriatic being required to secure full dilatation. One of the first symptoms of hyperemia of the iris is the pericorneal congestion, which is of the character peculiar to affections of the uvea and cornea, and consists of a number of very fine vessels situated in the episcleral tissue and running out in straight lines from the corneal margin, forming, as it were, a sort of fringe to the latter structure.
Etiology. Hyperemia of the iris often leads to inflammation of the iris; indeed, it might be said that every iritis is preceded by a stage of hyperemia. The cause of hyperemia, then, may be sought for in anything which will produce an iritis. Inflammation in structures anatomically connected with the iris may bring about hyperemia in the latter; for instance, keratitis, particularly the phlyctenular form. A foreign body on the cornea or the effect upon the cornea of a caustic agent will produce very quickly hyperemia of the iris. Inflammations of the choroid and ciliary body are fruitful sources of this phenomenon, and the same may be said of affections of the sclera; for instance, episcleritis.
Treatment. Rest, dark glasses, and the instillation of atropin. Ali investigation into the cause of the Hyperemia will suggest the proper general treatment.
Iritis (Inflammation of the Iris). The two most frequent causes of iritis are probably syphilis and rheumatism, and yet there is no constant and dis¬symptom by which we can infallibly recognize which diathesis is present. Symptoms which one author regards as characteristic of syphilitic iritis are mentioned by another as belonging also to rheumatic iritis, and vice versa. If all cases of iritis of syphilitic origin presented the characteristic formation of nodules, it would be reason enough for making syphilitic iritis one grand division of the subject; but, in spite of the fact that by far the majority of cases of iritis are due to syphilis, the appearance of nodules (macroscopically) is the exception rather than the rule.
Iritis of rheumatic origin is supposed by some authors to be peculiar in its great tendency to recurrence, but it is doubtful whether iritis of this type possesses greater liability to recur than the syphilitic form. Exception might be made of those cases of iritis seen with arthritis deformans, especially in young persons. In such cases the prognosis is bad, owing to the persistency (of the constitutional affection. Iritis of syphilitic origin is constantly encountered where recurrent attacks have been making their appearance for years. In both syphilis and rheumatism iritis will be apt to reappear so long as the constitutional disease is present. Inasmuch, then, as it confuses the sub to treat it from a diathetic point of view, the old divisions of iritisplastic, serous, and parenchymatous although by no means free from objections, will be followed.
Objective Symptoms. The disease in general is characterized by all the symptoms which have been described in connection with hyperemia of the iris, except that these symptoms now are more intense and are associated with an exudate. This exudate may be thrown out from the posterior surface of the iris and into the posterior chamber, causing adhesions between the anterior surface of the lens capsule and the posterior surface of the iris (posterior synechie). Sometimes, though not often, there is complete adhesion of the posterior surface of the iris to the anterior surface of the lens a condition known as total posterior synechia.
The exudate on the posterior surface of the iris is found in the pigmentary layer, and the region where the synechie are most apt to occur is about the pupil, for here the iris is in contact with the lens capsule. The exudate may be found also on the anterior surface of the iris, and it may be thrown out into the aqueous humor, and, dropping to the bottom of the anterior chamber, form a hypopyon'; or it may be found in the cornea in the shape of small points situated in the membrane of ]Descemet (so called keratitis punctata, see page 327). Sometimes the exudate is poured Out into the pupillary field, in which case it usually proceeds from the anterior surface of the iris. In such cases the iris reflex is lost. Finally, the exudate occurs in the substance proper of the iris, and shows itself by swelling of the iris, which is often thrown into folds.
It may be stated broadly that when the exudate is mostly confined to the region about the pupil we are dealing with plastic iritis; that when the exudate is found in the anterior chamber and upon the posterior surface of the cornea we are dealing with serous iritis; and, finally, that when the iris is swollen and thrown into folds we have before us the parenchymatous variety of the disease.
According to De Weeker, neither the plastic nor the serous form of iritis is apt to leave lasting changes in the iris, while in parenchymatous iritis there is more or less obliteration of vessels and disappearance of pigment.
Iritis Simplex or Plastic Iritis. Pericorneal congestion is always present in this form of iritis, and its varying intensity offers good evidence of the grade of the disease. In very light eases of plastic iritis the pericorneal congestion may be so insignificant as easily to be overlooked, while at other times it may show itself in chemosis, though this is rare even in the most intense inflammations of the iris. The cornea does not participate, though on superficial glance this does not seem to be the case. Oblique illumination, however, will show that what at first sight seems to be a dulness of the cornea is nothing more than a loss of the iris reflex, due to the exudate upon the anterior surface of the iris and to the slightly cloudy aqueous humor. A cloudy aqueous humor is not a noticeable feature in this variety of iritis, while it is a condition quite characteristic of serous iritis.
The pupil is contracted and sluggish, and shows no response to the usual tests. This condition of the pupil often persists in spite of the use of a mydriatic, and frequent instillations will be necessary to get the same dilatation which ordinarily can be obtained by one instillation. The explanation of this must be sought for not only in the ciliary irritation, and in the diminished activity of the dilator fibers caused by their infiltration with inflammatory products, but also in the necessary loss of activity in a tissue which is inflamed and swollen; and, finally, in the presence of the exudates which bind the border of the pupil to the anterior capsule of the lens. These exudates may be seen by oblique illumination. Several instillations of atropin will bring out strikingly the deformities in the pupil; those parts of the pupil which are not adherent will respond to the mydriatic, while the points which are bound down to the lens will remain fixed.
Sometimes the entire pupillary margin is adherent to the capsule of the lens a condition known as seclusion of the pupil. This kind of synechia is not usually the result of' one attack of iritis, but is found as a sequel of several recurrent attacks. At other times the pupillary field is completely filled with a mass of exudate, producing the condition known as occlusion of the pupil. If the adhesions are slight, they can be broken loose by the action of atropin, and when this is done small pigment specks may be seen on the surface of the lens, marking the points where the iris was adherent.
Serous Iritis. Instead of a plastic exudate, there may be an exudate, serous in character, containing solid elements, which are always to some extent deposited upon the posterior surface of the cornea. There seems to be an increased secretion of the aqueous humor, and the latter is quite cloudy. The deposits upon the membrane of Descemet are sometimes very fine, and are to be seen as small whitish or yellowish white dots which can be brought out by oblique illumination or by examination with a strong convex lens (see Fig. 221). These deposits are sometimes found on the anterior capsule of the lens. Synechie are not as prominent symptoms in the earlier stages of this variety of iritis as they are in the plastic form, although they appear ultimately and contribute very materially to the grave prognosis.
Atropin, therefore, will not disclose irregularities in the contour of the pupil to the same extent as in plastic iritis, and frequently the pupil is symmetrically dilated, though never ad maximum. The pericorneal congestion is usually slight. The tension, as a rule, is elevated, due, no doubt, to the hypersecretion going on within the eye. The pupil by its dilatation shows the effect of this increased tension.
It is more than probable that in serous iritis the entrance to Schlemm's canal is blocked with exudate a condition which of itself would be apt to bring about glaucomatous symptoms. As a rule, hypopyon is absent in serous iritis. Opacities in the vitreous body are very common, and degeneration of this part of the eye usually follows sooner or later. Ultimately, the inflammation affects the whole eye.
Parenchymatous Iritis. In this form of iritis the inflammation attacks the iris tissue itself. Instead of an exudate on the anterior or posterior surface of the iris, the exudate is found within the iris. The swelling, which is always present, is often circumscribed, and produces an impression as though there were nodules within the iris. The masses of exudate are pigmented, and are found around the pupillary margin, often binding the iris to the anterior capsule of the lens. Sometimes these exudates find their way into the anterior chamber, and, settling at the bottom of the latter, form hypopyon; at other times they are thrown out into the posterior chamber. Even the pupil is sometimes filled with these yellowish masses. The appearance of the iris is dull, and pericorneal congestion is usually intense. There often may be seen the formation of little yellowish red nodules traversed by blood vessels, practically what is observed in the so called syphilitic iritis, and designated iritis papulosa (Fuchs) when occurring in the secondary stage of syphilis; iritis gummosa, in the tertiary stage.
A typical parenchymatous iritis may be produced in rabbits by injecting a drop of a suspension of the staphylococcus aureus into the anterior chamber, the inflammation being attended with the formation of small elevations the iris and nodular masses at the pupillary border, not unlike the appearances visible in the same disease in man.
In parenchymatous iritis there is often present a pupillary membrane which stretches over the entire pupillary area. Sometimes a purulent infiltration of the iris (purulent iritis) occurs, with a deposit of leukocytes in the anterior chamber. Parenchymatous iritis, so long as it confines itself to the iris, may leave the eye unimpaired in its functions.
De Wecker calls attention to the peculiar nature of the hypopyon in these cases. It differs from the hypopyon seen in keratitis, because it is much thinner and changes its position with every movement of the head, and is remarkable for the rapidity with which it undergoes absorption, frequently disappearing in the course of a few hours.
Subjective Symptoms of Iritis. While iritis may exist without pain (as is often the case in the serous form), as a rule this is a prominent symptom. The pain is not referred so much to the eyeball as to the temples and forehead and the neighboring regions supplied by branches of the fifth pair, and is of a boring character and apt to be more intense at night. The pain is Dot only the result of pressure upon the ciliarv nerves by the products of the inflammation, , but also the result of an actual involvement of these nerves in the inflammatory process. Pain, however, is no absolutely reliable index of the grade of an iritis. Plastic iritis, as a rule, is characterized by more pain than the parenchymatous form, yet one would be disposed to expect the opposite.
Fournier,' among others, has called attention to the fact that parenchymatous iritis, in spite of the extensive anatomical changes present, is often associated with little or no pain.
Lachrymation and photophobia vary with the ciliary neuralgia. Visual disturbance is always present, and varies in degree with the clouding of the aqueous humor and with the extent to which the pupillary area is occupied with exudates. In serous iritis the disturbance in vision may be explained by changes in the vitreous body and choroid, and even in the optic nerve finall, such constitutional symptoms as fever and nausea have been occasional observed, and a coated tongue is a frequent accompaniment.
Etiology. The causes which give rise to iritis are local and constitutional. Among the first class are foreign bodies in the cornea, which have remained there for a considerable length of time ; the careless and continued use of caustic agents; penetrating wounds of the eyeball; and swollen masses of lens matter. Iritis may arise from an inflammation of the cornea, sclera, ciliary body, or choroid, in which cases iritis extends by continuity of tissue. Finall , iritis may arise from trouble in the other eye sympathetic oph¬thalmitis.
Among the diatheses which give rise to iritis, syphilis stands easily first. Indeed, nearly 75 per cent. of all cases of iritis can probably be traced to this source. The iritis is generally of the plastic variety, although the parenchymatous form may occur. If shows itself generally in the secondary stage of syphilis, and when the parenchymatous form of the disease prevails there are often seen small nodules either at the margin of the pupil or at the ciliary border of the iris, and at these points there are usually synechie. When the nodules disappear there may remain in the iris atrophic areas. While the presence of these nodules probably justifies the surgeon in diagnosticating the case as one of syphilitic iritis, it should be remembered that in the majority of cases of iritis, where a syphilitic origin is clearly demonstrable, apparently no nodules are present. The nodules may attain quite a large size, and several of them may fill the anterior chamber, and, increasing in size, may burst through the envelopes of the eye. This termination is rare. Hereditary syphilis seldom gives rise to iritis, and when it does the subjects are usually young people, just as is the case with interstitial keratitis.
Rheumatism (articular) is another not infrequent cause of iritis. Two such cases the writer has in mind one, a boy fourteen years old, who has not walked for four years, and who is completely disabled from articular rheumatism ; the other, a young woman nineteen years of age, who has been confined to her bed for eight years. The girl has only light perception, her pupils being entirely bound down by adhesions, while in the case of the boy there is seclusion of the pupil in one eye, and the other eye possesses only sufficient sight to allow him to see large objects. Both these patients have had skilful treatment, which has availed but little, owing to the intensity of the constitutional affection.
It is doubtful whether the rheumatic diathesis gives rise to distinctive ocular symptoms though some authors speak of the peculiarity of the episcleral and pericorneal congestion. As might be inferred, rheumatism of the character seen in the two cases just mentioned, when associated with iritis, would probably be the occasion of recurrent attacks of the eye affection. In this connection it should be said that gout often gives rise to iritis.
Gonorrhea sometimes causes iritis. In such a case no doubt there is a general infection, although it is not at all probable that the gonococcus gets into the intraocular circulation, but its toxins reach the eye and there give rise to iritis. Inflammation of' the knee joint commonly precedes the eyeaffection. When iritis is found as a result of gonorrhea, it shows a tendency to recur, and is frequently associated with a renewal of the pains and swelling in the joint.
Scrofula (scrofulous iritis) sometimes, but rarely, gives rise to iritis, and, as is the case with hereditary syphilis, the subjects are young persons. According to Fuchs, iritis in these cases is marked by the appearance of lardaceous looking deposits or exudates, which seem to grow out from the sinus of the chamber. Anemia may character.
Relapsing fever (iritis in acute infectious diseases), typhus and typhoid, smallm pox, cerebro spinal meningitis, pyemia, and even epidemic influenza (grippe), have been known to cause iritis. Inflammation of the iris in relapsing fever is very tedious in its course. Iritis is occasionally caused by malaria (periodic iritis) and by irregularities of menstruation (iritis Catamenalis).
Diabetes (diabetic iritis) is another very rare cause of iritis. In spite of the fact that hypopyon is often observed in this variety of iritis, the course of the disease is usually favorable.
Tuberculosis in other organs may give rise to iritis (tuberculous iritis), although such an origin is not often seen. Tuberculosis shows itself in the iris either in the form of grayish red nodules or as a solitary tubercle resembling a neoplasm. Children are usually the subjects. While it is a very rare affection, its nature is well understood, for Cohnheim has produced the disease experimentally in rabbits by introducing small pieces of tuberculous material into the anterior chamber. The immediate effect of this operation is apparently negative, but within a month iritis sets in and the characteristic gray nodules appear. These increase in number till they fill up the anterior chamber, when (unless the animal dies) they may break through the coats of the eye. This is the disseminated form of the affection.
The little nodules are usually located at the pupillary margin. In man the disease is generally followed by a plastic irido cyclitis and loss of the eye.
tuberculosis of the iris also occurs as a solitary tubercle. This tubercle more often appears alone, though it may exist along with the nodules. When alone the symptoms of iritis can be absent that is, for a certain period of its history although iritis ultimately appears. It was regarded by von Graefe at first as a tumor, and described as such under the name of granuloma. Haab first demonstrated its true nature.
The disseminated form may occur in both eyes, but the solitary form has only been observed in one eye. In both varieties the eye is usually lost.
Mention may be made here of what has been called recurrent iritis, where the patient for months may be free of' the disease and suddenly an outbreak will occur. Both eyes are usually affected, but rarely at the same time. Synechie are frequently left after an attack, and it has been thought that their presence determined subsequent attacks, but it is more than probable that some persistent constitutional affection (generally syphilis) is responsible for the recurrences. It has been observed that men more often than women are the subjects of this variety of iritis.
Traumatism is responsible for a number of cases of iritis. The injury may be accidental, or may be inflicted during the course of an operation, or occur as the result of an operation e. g. after discission of the lens.
No time of life seems exempt from iritis, although it is exceptionally seen in children under ten years of age, and it is not often met with after the seventieth year. According to von Ammon and von Arlt, iritis is more frequent in men than in women.
Pathological Anatomy. The iris is thickened and infiltrated with round cells. This round cell infiltration will be found marked along the blood vessels. The exudate is composed of fibrin filled up with leukocytes and round cells, and is generally more extensive upon the posterior surface of the iris. When found in the pupillary field the exudate is rich in pigmentgranules, although this is the case to a certain extent everywhere. The coats of the blood vessels are thickened and capillary hemorrhages are abundant Masses of granular debris, the exact nature of which it is difficult to determine, are always present. In cases where seclusion of the pupil has occurred it will be found that the iris has undergone atrophy in those parts bordering upon the pupil. Where the entire posterior surface of the iris is bound down to the lens, sooner or later atrophy of the whole iris occurs, and it will be found that all that is left is a thin membrane, and here and there within its folds a clump of disintegrated cells. Sometimes there are scarcely any traces of the structure of the iris ; even the sphincter has disappeared.
Diagnosis. The character of the conjunctival congestion, the slightly turbid aqueous, and the sluggish pupil in iritis distinguish it from conjunctivitis. If the two irides are compared, the change of color of the affected iris, due to hyperemia, will be observed. In conjunctivitis the pain is burning in character, is referred especially to the lids, and is quite constant, while in iritis it is usually paroxysmal, is referred to the temples and brows, and often is more intense at night. Vision is never materially affected in simple conjunctivitis, while visual disturbance in iritis is the rule. Iritis may be distinguished from glaucoma (with which it is often confounded by the inexperienced) by the size of the pupil, which in the former disease is contracted, while in the latter it is dilated. The tension, while it may be elevated in iritis (particularly in the serous form), is not so as a rule. The tension in glaucoma is always elevated.
Prognosis. This depends upon the cause and also upon the changes which have already taken place in the iris. If the pupil is completely dilatable with atropin, the prognosis may be regarded as favorable. The presence of numerous synechie, especially when one or more fail to yield to the action of the mydriatic, means often a recurrence of the iritis, although cases are not infrequently seen where two or three synechie have been present for several years, without recurrence of the iritis; and with good vision. Where there is either seclusion or occlusion of the pupil, an accumulation of aqueous often occurs in the posterior chamber, and leads to a bulging forward of the iris and ultimately to increased tension (secondary glaucoma). Where there is a total posterior synechia, the iris instead of bulging forward may be retracted at its periphery, and here we will have usually diminished tension. Sometimes the iritis runs a chronic course, being characterized by sluggishness of the pupil, cloudy aqueous, an occasional synechia, and by usually no marked painful symptoms. The conditions just mentioned mean that the eye has been the seat of disease for a considerable time, that in consequence the integrity of the lens (so called inflammatory cataract), of the ciliary regionin fact, of the whole posterior segment of the eye has been in a measure permanently impaired. The prognosis then is bad for anything like restoration of good vision.
The condition of the adjacent structures has an important hearing upon the prognosis.
Treatment. In connection with the treatment of iritis the following rather striking sentences seem appropriate: " There is one ground, however, on which I strongly object to this ticketing of iritis with the names of various diseases namely, that habit is likely to mislead the inexperienced practitioner into an endeavor to treat the name on the ticket, while the iritis may be neglected until it has done irreparable harm. I do not know of any disease which prevents the occurrence of iritis, and hence I do not know of any with which it may not sometimes be associated . . . . . We do not understand a given case one whit better for calling it I rheumatic,' and the term tends to relegate to the second place, as a mere accident of another affection, a malady in which all our skill will be necessary if we are adequately to discharge our responsibilities to the patient" (Robert Brudenell Carter).'
Rest for the iris is reached by the instillation of atropin. This drug paralyzes the sphincter, stops the incessant movements of the pupil, reduces the hyperemia, and by dilating the pupil breaks loose the adhesions, which are Dot likely to recur during mydriasis. Atropin is to the eye in iritis very much what opium is to inflammations elsewhere in the body: it is, so to speak, the great anodyne in iritis. Generally, a solution of four grains to the ounce is strong enough to dilate the pupil if instilled every three or four hours; but if a solution of this strength does not produce the desired effect, a stronger one should be employed. Not infrequently success is attained only after using a solution of sixteen grains to the ounce. The surgeon should watch for the constitutional effects of the drug, but an iritis which calls for such a strong solution of atropin is apt to tolerate it without unfavorable results. No more than one drop is instilled at a time, and not oftener than ever y four hours. If constitutional effects appear, the strong solution should be abandoned at once, but ordinarily two or three instillations will give factory evidence whether any good will follow its continued use. The employment of cocain along with atropin, heightens the effect of the latter drug.
The appearance of constitutional symptoms, however, no matter what be the strength of the atropin solution, necessitates a withdrawal of the drug, as well as of other mydriatics, such as scopolamin, duboisin, and hyoscyamin. When a full dilatation of the pupil is obtained, it may be no longer necessary to use the atropin so often ; in other words, its use should be regulated by the condition of the pupil.
Hot applications, either moist or dry, are indicated. A small pad of surgical gauze steeped in the following lotion and applied to the eye as hot as can be borne rarely fails to give comfort . Plumbi acetat., 3j ; opii pulv. 3ss; aq. bull., Oj. X roll of dry cotton and then a layer of oil silk should be placed over the pad. As soon as this application gets cool it should be renewed. Its good effects are especially evident when the inflammation is of a violent type. Poultices are valuable and are often employed. Cold applications are to be avoided, although some surgeons advise their use in traumatic iritis. Four or five leeches applied to the temples or the artificial leech (Heurteloup) are helpful in bringing about an abatement of the inflammatory symptoms, although this method of treating iritis has become less popular of late years. The Japanese stove or hot box is a most convenient method of applying dry heat. The box should be wrapped in a handkerchief or in any soft material and applied to the eve. A little bag filled with hops or bran and heated in an oven can be used in the same way. These various methods of applying beat are valuable, especially the first one.
According to Fuchs, Schweigger, and other writers, a hypodermic injection of muriate of pilocarpin (1/4 grain) every other day is very beneficial. Bro and opiates are to be used when needed. So far as possible, the patient should be screened from direct rays of light. The administration of calo in the earlier stages of the affection usually proves advantageous. Two grains are given in ' grain doses. The good effects of' this agent in all forms of iritis are most conspicuous. Not infrequently in cases in which atropin apparently has produced no mydriasis, after a thorough calomel action marked improvement in the condition of the pupil may be observed.
After the action of the calomel has been obtained treatment should be directed to the cause of the iritis. As a rule, the administration of salicylate of sodium in 20 grain doses, every three or four hours, will be found an admirable remedy in the painful stage of iritis. It matters not what be the origin of the disease, this remedy rarely fails to prove serviceable. After the painful stage has passed away this drug may be administered in smaller doses if there be a rheumatic or gouty diathesis present; if the iritis rests upon a syphilitic basis the surgeon should resort at once to biniodid of mercury and iodid of potassium, or inunction of blue ointment may prove tile best method of getting the mercury into the system. A mercurial vapor bath is also an excellent way of administering this remedy. Usually the mixed treatment is adopted in such cases, and, as has been said, this consists in the administration of the biniodid of mercury and iodid of potassium, which is continued Dot only till all the eye symptoms have disappeared, but until one can be reasonably certain that the constitutional poison has been eliminated. Subconjunctival injections of bichlorid of mercury have been recommended by Darier and other surgeons; similar injections of physiological salt act equally well.
Iritis is uncommon in children, and is best treated by inunctions of mercury. In serous iritis the surgeon should be careful in the employment of atropin, as a glaucomatous condition often exists which the mydriatic would tend to intensify. Paracentesis may be practised in these cases with advantage, and when increased intraocular tension persists iridectomy is indicated.
The majority of cases of iritis, properly treated, get well without adhesions; still, synechie may remain and may cause recurrent attacks. The operation of corelysis, which is not much practised now a days, was designed for the purpose of breaking loose these adhesions (see page 579). Whenever it is necessary to operate upon synechie no procedure is superior to iridectomy (see page 575). The presence of several broad synechie near one another might readily explain the occurrence of frequent attacks of iritis. Such synechie should be operated upon by an iridectomy at the point of attach One or two synechie are rarely responsible for a recurrence of iritis. Operative measures in connection with iritis are rarely demanded during the active inflammation, but rather in the sequele of the disease.
In those cases where the iritis has resulted from an injury, if there are any large pieces of iris protruding they should be abscised. A minute hernia, however, will probably do no harm and had best be let alone. The inflammation itself should be treated just as we would treat any plastic iritis. When the lens capsule has ruptured and the swollen masses of lens are pressing upon the iris the lens should be removed. In cases of seclusion occlusion of the pupil iridectomy is indicated. Either of these conditions, if neglected, may end in total blindness. In seclusion, iridectomy is demanded because it relieves increased tension and re establishes the communication between the anterior and posterior chambers and by doing this the nutrition of the eye is at once improved and some vision may be obtained. For the same reasons iridectomy is demanded in occlusion of the pupil. But even in those cases where the intraocular tension is lowered and atrophy has set in, as is sometimes the case after total posterior synechie, the tendency of iridectomy is to do good by improving the condition of the eyeball. 'Such eyes may fill out again and regain some sight. Where the entire posterior surface of the iris is bound down to the lens capsule it is difficult to pull away the iris without more or less injuring the delicate ciliary region ; hence iridectomy in such cases may be followed by irido cyclitis, but inasmuch as such an eve will in all probability cause trouble in one way or another, iridectomy should be tried.
ANOMALIES OF THE ANTERIOR CHAMBER.
The depth of the anterior chamber varies within physiological limits. In infancy the anterior chamber is very shallow, becoming deeper a , adult life, is approached, while in old age it again becomes shallow. In myopia the anterior chamber is deeper than in hyperopia.
Pathologically, the anterior chamber shows variations in depth. It may be shallow from the pulling forward of the iris by anterior synechie or by the collection of masses Of exudate behind the iris in total posterior syneehie. Sometimes the periphery of the anterior chamber is deeper than the middle after a severe attack of cyclitis, and in these cases the outer zone of the iris is drawn backward by exudates. A shallow anterior chamber occurs in g aucoma, and also after the needling operation for cataract, when the lens swells up and presses against the iris, pushing it forward. A shallow anterior chamber is seen in the later stages of intraocular tumors.
Increased depth of the anterior chamber is seen in staphyloma of the cornea, in luxation of the lens into the vitreous body, in aphakia, and in hydrophthalmos.
The contents of the anterior chamber may be altered by the presence of blood (hyphema), pus, masses of lens substance, foreign bodies, cysticerci, neoplasms, and cilia.
Blood in the anterior chamber as a general thing will disappear under a compress bandage, but if it persists and is evidently acting as a foreign body, paracentesis of the anterior chamber at its lower border should be performed. Hyphema most often follows injuries and contusions of, and operations upon, the eyeball. It is also seen after irido cyclitis, with seclusion of the pupil and beginning phthisis bulbi, in which case the hemorrhage into the anterior chamber often repeats itself. Paracentesis tinder these circumstances does Do good, the compress bandage being found more serviceable. Hyphema has been observed as a result of dysmenorrhea and purpura hemorrhagica. Mooren and Weber describe patients who could bring on hemorrhage into the anterior chamber at will. Pus in the anterior chamber (hypopyon) is always a symptom, and must be treated according as it proceeds from the cornea or from the iris. It usually has its origin in affections of the cornea.
Foreign bodies, as particles of steel and glass, may pass through the cornea and rest in the anterior chamber and on the iris. AD eyelash may find its way into the anterior chamber, and after a time give rise to an implantation cyst (see page 489).
Cysticerci are rarely seen in the anterior chamber. The parasite generally gives rise to symptoms of iritis, and can be seen sooner or later swim ¬around in the aqueous humor or it may be attached to some point of the iris. The filaria sanguinis hominis has also been observed in this locality. The parasites should be removed.
DISEASES OF THE CILIARY BODY.
Cyclitis. Inflammation of the ciliary body does not exist as an isolated disease, but 'is usually an extension of an iritis or choroiditis. As a rule, iritis is present.
Etiology. Inasmuch as the disease is secondary to' either iritis or choroiditis, more often to the former, it has the same etiology. When it is not secondary to one of these affections it is the result of a wound or foreign body in the ciliary region or it may occur in one eye as the result of a traumatic cyclitis in the other (sympathetic ophthal Symptoms. The disease is characterized by marked circumcorneal congestion and more or less hyperemia of the iris, which shows itself in dilatation of the blood vessels and slight discoloration. The anterior chamber is deeper than normal at its periphery, owing to the traction of exudates from behind. These exudates are plastic in character hence the name plastic cyclitis and usually are not seen in the pupillary field. The pupil is often dilated. The hyperemia of the iris sooner or later passes over into iritis, and finally the choroid becomes involved. Sometimes these symptoms are much less pronounced; indeed, there may be entire absence of plastic exudates, and, while in the beginning the anterior chamber is deep' later on it becomes shallow. A condition may arise very similar to what is seen in serous iritis. Fine opacities make their appearance in the anterior part of the vitreous bodyopacities which materially interfere with vision. The tension is decidedly elevated and the pupil dilated. Some authors speak of this somewhat milder aspect of the disease as serous cyclitis. Again, we may have the pericorneal congestion and hyperemia of the iris intensified, and this hyperemia may extend to the retinal vessels, showing itself in tortuosity of the retinal veins. A characteristic symptom is hypopyon, which disappears and reappears again in a few days. This is the purulent type of the affection, and it is generally spoken of its purulent cyclitis. Just as in the plastic and serous types, the iris is always implicated.
Cyclitis is characterized by the general symptoms of inflammatory irritation namely, ciliary neuralgia, photophobia, and lachrymation. The eyeball is exceedingly sensitive to the touch over the ciliary region. Vision is invariably impaired.
Pathological Amatomy. Small cell infiltration of the ciliary body is present, and this condition is especially marked in the purulent variety of cyclitis. Hemorrhages are frequent in all forms of cyclitis. Both the circular and radiating fibers of the ciliary muscle contain exudate, and this exudate (fibrinous) is considerable enough at times to push aside the individual fibers. The neighborhood of Schlemm's canal is always densely infiltrated, and no doubt the inflammatory products in this locality by blocking up the entrance into the canal have not a little to do with the development of glaucomatous tension. The formation of membranes is usually seen. The cyclitic membranes may cover the entire posterior and anterior surface of the iris, and also the ciliary body, and even extend into the vitreous body. This membrane not infrequently envelops the lens, and, contracting about it, cuts it off from its sources of nutrition. As a result of this the lens is often found as a small calcareous mass entangled in the meshes of the membrane and bearing no resemblance to its former shape. In the contraction which the cyclitic membrane undergoes the ciliary body is drawn away from its normal site, and is to be seen as a narrow strip of tissue, having lost its natural shape. This cyclitic membrane is composed of connective tissue with interlacing hands. All shapes of cells will be found present. In very light eases this membrane may disappear by resorp¬tion. Masses of black pigment are to be seen here and there throughout the diseased parts. According to Pollock, Hemorrhages are common in the cyclitis membrane, although the author has not observed any in the speci¬mens which have come under his observation. In the early stage the ciliary processes are thickened; finally, however, they undergo atrophy and become very much thinned. When the process has reached this stage atrophy of the eyeball is usually only a question of time.
Diagnosis. The question is between iritis and irido cyclitis. The symptoms which determine the existence of a cyclitis have been enumerated by Fuchs as follows: Inflammatory symptoms of considerable degree, especially if edema of the upper lid is present (this edema of the lid does not occur in pure iritis) : sensitiveness to touch in the ciliary region ; retraction of the periphery of the iris, indicating total posterior synechie ; disturbance in vision more considerable than would be expected from the opacities within the confines of the anterior chamber; and, finally, tension either elevated or lowered.
Prognosis. The prognosis in cyclitis is always grave, especially so in the plastic form. The cyclitis membrane usually covers the entire ciliary region, and in the contraction and organization which follow the retina and ciliarv body are torn out of position, the lens undergoes degeneration, and atrophy ends the scene.
The serous form in its early stages is often characterized by a glaucomatous condition which is followed by softening and atrophy of the eyeball.
The purulent form of cyclitis, seen as a result of infection after cataract extraction, as a rule ends in sloughing of the whole eyeball.
Treatment. The treatment is practically the same as that employed in iritis. Heat and atropin, then, should be used locally. The latter remedy is withdrawn when a glaucomatous condition is present. The constitutional treatment which has been suggested in connection with iritis is equally applicable here.
Injuries of the Ciliary Body. Injuries of the ciliary body arise from penetrating and non penetratiDg wounds of the ciliary body, and are fully described on pages 364 and 367.
Irido choroiditis (Chronic Serous Irido choroiditis). This disease usually originates in the iris ; that is to say, the presence of posterior Synechie may result in chronic iritis which passes backward and invades the choroid. Sometimes the inflammation originates in the choroid and passes forward and involves the iris.
Etiology. Old synechie are generally responsible for this affection. Where the disease starts in the choroid it not infrequently is to be attributed to a dislocated lens which has been either resting upon the retina and choroid or floating about in the vitreous body. Edward Meyer mentions instances where the affection was traceable to menstrual disturbances and to the climacteric.
The pathological anatomy is practically the same as that which has been described in connection. with Iritis.
Symptoms. Even when the process has originated in the iris the irritative symptoms are never conspicuous, certainly not to the extent in which they are found in iritis. The iris is often bulged forward, and may be press against the cornea. This condition, however, is only seen in those cases where the pupil is completely occluded and communication between the two chambers is interrupted. It is caused by the collection of effusions behind the iris. The vitreous body is generally filled with opacities. Pain, as might be expected, is an insignificant symptom. Visual disturbance is always present, and is in proportion to the condition of the pupil and involvement of the choroid.
Where the inflammation has started in the choroid the visual disturbances are more pronounced. Nearly a] ways in this event there are detached retina, dense opacities in the vitreous body, and a degenerated lens. By the time the inflammation reaches the iris sight has been nearly extinguished. From now on the symptoms resemble those seen when the inflammation originates in the iris. Meyer has suggested the following points as important in deciding as to the probable origin of the affection, whether in the iris or choroid : In case the inflammation had started in the iris the patient would be apt to recall some attack of iritis, and it would be noticed that the structure of the iris had undergone changes to some extent, being discolored and atrophied. As a rule, the lens shows Do participation in the affection till the process has found its way backward. When visual disturbances are absent one can be reasonably certain that neither the len's nor the vitreous body is to any extent involved.
If the process has started in the choroid, visual disturbances will always be prominent features, owing to the opacities in the vitreous body. Retinal detachment, will be noticed, the intraocular tension will be lowered, and the lens will often be found to have undergone calcification. Neither of these forms exhibits acute symptoms, both being very insidious in character.
Prognosis. Where the process has started in the iris and has been properly treated in the early stages there is, comparatively speaking, hope for restoration of useful sight. But where the disease begins in the choroid the outlook is exceedingly bad. Even if the retina is Dot detached or the lens opaque, the integrity of the entire uveal tract has been to some extent permanently impaired.
Treatment. Atropin must be employed, but it should be remembered that intraocular tension is sometimes elevated in the course of the disease. When the communication between the anterior and posterior chamber is interrupted, iridectomy should be performed, for a continuance of this condition means blindness. The surgeon should not hesitate to repeat this operation as often as the new pupil is closed with exudates, and should not be deterred even by a condition of diminished tension. The lens being diseased and more or less opaque, its removal is frequently indicated Constitutional treatment should not be neglected. Mercury should be tried in the form of the bichlorid and in small doses. Iodid of potassium is also indicated.
SYMPATHETIC AFFECTIONS OF THE EYE.
Sympathetic Ophthalmitis. This disease is one of the most interesting and at the same time the most obscure in the whole range of eye affections.
Definition. Sympathetic oplithalmitis is an inflammation, usually plastic, but sometimes serous. Which affects the iris, ciliary region, and choroid of one eye ("the sympathizer"), and which originates in a traumatic inflammation of the same parts in the other eye (11 the exciter "). The three fundamental elements of true sympathetic ophthalmitis are first, a traumatic irido cyclitis of one eve; second, a plastic uveitis of the other eye; and third, a certain period of time which always elapses before the outbreak of the sympathetic disease i. e. the period of incubation. The existence of these three factors certainly warrants the diagnosis of sympathetic ophthalmitis.
Etiology. Penetrating wounds are chiefly concerned in the production of sympathetic ophthalmitis wounds either from sharp instruments, such as scissors and knives ; or wounds caused by the entrance into the eyeball and the lodgement there of small fragments of steel, percussion caps, particles of stone or glass. Schirmer, Mackenzie, Knapp, and others report cases which followed simply a blow upon the eyeball without a rupture. This mechanism is entirely contrary to the rule, and most of these instances are open to grave criticism.
Penetrating wounds of the ciliary region are especially apt to give rise to the disease, and it makes no difference whether the wound is large or small. Mooren has described sympathetic ophthalmitis after the entrance into the eyeball of small particles of iron, and has seen it follow the bursting of the eye by a blow with a stick. According to Mackenzie, protrusion of the iris and its incarceration in the wound are conditions which are peculiarly liable to give rise to the disease.
Wounds which pass through the cornea and the pupillary border of the iris, even though the lens is injured and cataract results, are not as dangerous as when the wound passes through the ciliary border of the iris. Traumatic cataract of itself has no significance in the etiology of sympathetic ophthalmitis though a swollen lens, by pressing upon the surrounding parts, can certainly aggravate an already existing cyclitis. The operations of iridodesis, discission, iridectomy, reclamation, and cataract extraction have been followed by sympathetic ophthalmitis. Mackenzie states in his book that he never saw sympathetic ophthalmia follow any of the operations for cataract. Among other causes mentioned by most writers are intraocular tumors, particularly the melano sarcomata, and cysticercus is reported to have given rise to sympathetic ophthalmitis (two cases). There are good reasons, however, for regarding both sarcoma and cysticercus as very doubtful agents in the production of the affection, and the same may be said of ossification within the eye.
Symptoms. Accornmodative asthenopia is the first symptom, and shows itself on the slightest attempt to fix an object, no matter of what size or at what distance. This symptom may be lacking, and instead of it the patient sees a mist around everything. Pain is usually absent, but pressure oil tile ciliary region elicits tenderness which is often quite characteristic.
Pericorneal congestion is more or less marked. The media are cloudy. The earlier stages of the affection are associated with slight increase in intraocular tension, followed by vacillating conditions of tension, mounting up to a high grade in the glaucomatous stage, while at the last the tension is much diminished. The iris is hyperemic. Pagenstecher has called attention to the fact that in this kind of' iritis the pupil can readily be dilated in spite of the synechie. It is possible for the process to disappear at this point and never return, but this is seldom the case. The attacks come at frequent intervals and with renewed intensity. After every recurrence the synechie are firmer and the pupil is harder to dilate. Pain may Dow develop. Small grayish dots appear on the posterior surface of the cornea. Synechie are to be seen extending all the way around the pupil. Recession of the iris periphery is present.
In nearly every case the primarily affected eye is blind before the outbreak of the sympathetic disease; but cases are on record where vision was still present in the injured eye at the time of the appearance of the sympathetic inflammation. The following constitutional symptoms may be seen: a quick pulse, thirst, pallid complexion, and obstinate constipation.The course of the disease is usually tedious.
Sympathetic serous iritis is a much milder type of the disease. The symptoms are those of serous iritis. This may be regarded as a comparatively benign form of sympathetic ophthalmitis, which may pass over into tile pernicious form plastic irido cyclitis which has been described above.
Sympathetic papillo retinitis has been observed a certain Dumber of times, and, in contradistinction to the genuine sympathetic ophthalmitis, shows no tendency to relapses. Schirmer states that the disease has never been observed after the enucleation of the injured eye. It is a benign affection, and restoration of sight is the rule. A sympathetic choroido retinitis has also been described.
Diagnosis. The disease has no peculiar train of symptoms by which it can be invariably recognized. If pronounced objective symptoms of a plastic irido cyclitis appear in an eye which had remained sound for three weeks after the fellow eye had been the seat of a traumatic irido cyclitis, the case may be regarded as one of sympathetic ophthalmitis. The diagnosis will be freer of doubt if three weeks is considered as the earliest (late for the outbreak of the sympathetic affection; later than the fourth month the diagnosis becomes more or less uncertain.
Mackenzie says that the disease may be complicated with scrofula and assume a good deal of the scrofulous character, or it may be complicated with syphilis. Cerebral complications have been mentioned in connection with sympathetic ophthalmia.
Sympathetic Irritation. This condition was once regarded as simply the forerunner of sympathetic inflammation ; but it is a much more frequent affection than the latter disease, and differs from it in several vital points. Photophobia, lachrymation, pains in the bead and orbit, and blepharospasm are frequently present. The affection reminds one somewhat of phlyetenular conjunctivitis. The neuralgia is often remittent in character and very violent. There is concentric narrowing of the field of vision. Shadows and clouds are often seen when an effort is made to look at an object. More or less obscuration of objects occurs from time to time, the obscuration lasting several seconds, and then the objects appear as distinct as ever. The pupil is generally small, but the movements of the iris are intact. According to Noyes, the range of accommodation is diminished.
The disease shows itself at periods ranging from two and three weeks to fifteen and twenty years after the injury of the first eye, and is communicated to the sound eye through the medium of the ciliary nerves.
Pathogenesis of Sympathetic Ophthalmitis. Up to 1858, Mackenzie's views prevailed pretty generally namely, that the optic nerve was the channel of communication. Mutter, however, concluded that the sympathetic disease was due to irritation of the ciliary nerves, together with an influence which affects nutrition, secretion, and accommodation. Muller's views gained many adherents, among others von Graefe; indeed, the so called ciliary nerve theory became at once the popular one, and remained so for a long time.
The optic nerve theory was revived by Horner and Knies in 1879.
1881, Snellen, Berlin, and Leber advanced the opinion that the disease was of parasitic origin.
Maats, under ponders' direction, in 1869 undertook the experimental solution of this problem, and his experiments were repeated at a later date by Snellen and Rosow. All three of these observers obtained negative results.
Of all the experimental work on this subject, that of Prof. R. Deutschmann of\ Hamburg has attracted the most widespread attention, and his results were regarded at first as absolutely conclusive. He claimed to have produced sympathetic ophthalmitis in the eye of a rabbit by injecting a drop of a suspension of the staphylococcus aureus into the vitreous body of the fellow eve. Quite a number of experiments were made, and he felt justified in the following conclusions: That sympathetic ophthalmia is a parasitic disease which makes its way from one eye to the other by way of the optic nerves and chiasm. The organisms work their way forward by reason of a certain impetus which comes from their growth, as well as from their power of spontaneous movement. In this way they reach the base of the brain, where they are swept down by the lymph stream into the sheaths of the opposite optic nerve, and thus reach the second eve. This movement on the part of the lymph strearn explains why the organisms do not spread themselves over the base of the brain and produce meningitis.
The experiments of Deutschmann were subjected to the closest scrutiny, and in spite of the work of Alt, Gifford, Mazza, Randolph, Limbourg and Levy, Schirmer, Greef, Ulrich, and Bach, there has never appeared ally evidence to lead us to believe that Deutsebmann's experiments are conclusive. In fact, the investigations of these observers strengthen the view which has been held, that sympathetic ophthalmitis cannot be produced in the lower animals, certainly not with the pus organism. From this it would seem that Deutschmann's work is by no means conclusive, and that it is more than probable that this observer fell into errors of interpretation. The pus organism probably plays no part in the production of the disease in man, as is illustrated by the rarity of sympathetic ophthalmitis after panophthalmitis, where the pus organisms are usually present in such great numbers.
Wounds of the ciliary region have been thought to peculiarly predispose to sympathetic ophthalmitis, but experiments on the lower animals have shown that so long as the instrument was sterilized the wound, no matter if located in the ciliary region, healed invariably with little or no inflammatory phenomena. Experiments of this character show that injuries in the ciliary region are not in themselves sufficient to give rise to sympathetic ophthalmitis, but that something else is necessary, a something modifying the character of the Wound itself. A wound, however, which is infected would, for sound anatomical reasons, be more apt to set up sympathetic trouble if located in the ciliary region than if located anywhere else in the eye. Reference here may be made to the works of Bach and Schmidt Rimpler, both of whom lean toward a somewhat modified ciliary nerve theory.
The uniformly negative results of the various experimenters do not disprove the bacteric origin of sympathetic ophthalmitis, but before regarding the theory as proved the specific organism must be identified.
Prognosis. The prognosis is always a matter of grave doubt. Wellestablished recoveries are rare. Waldispuhl, summing lip the statistics of Prof. Schiess's clinic in Me, reports four recoveries in ten years. Cases of recovery are reported by Hirschberg, Laqueur, Schirmer, Rogman, and Randolph. Relapses are the rule and this fact should lead us to be guarded in holding out the prospect of definite recovery. A patient who has passed two years without a relapse may be regarded as comparatively safe.
Treatment. The prophylactic treatment naturally plays a most prominent part in dealing with sympathetic ophthalmitis, and it seems clear that the only certain prophylaxis is the enucleation of the injured eye. When sympathetic irritation exists and there is no special reason for believing that sympathetic inflammation will appear, resection of the optic nerve may be substituted for enucleation. This is often the case in eyes which have been lost from other causes than from penetrating wounds; for instance, in abso glaucoma or where inflammation has destroyed the entire cornea and phthisis bulbi has followed. It would be safer to enucleate an eye blind from a penetrating wound. When the eve has some vision, it is an exceedingly difficult question to decide. The best guide in such a case is probably the tension and sensitiveness to touch. If the eyeball is sensitive to the touch and the tension diminished, and at the same time only light perception is present, the chances of improvement for this eye are bad, and especially so if these conditions persist for several days after the injury. In this case enucleation is indicated.
When the injured eye is blind and sympathetic irritation is present in the other eye, it is best to enucleate.
When the injured eye possesses a little vision and symptoms of irritation appear in the other eye, every effort must be made to improve the condition of the injured eye; and this means to apply the rules governing the treat of an irido cyclitis.
When sympathetic inflammation has broken out the injured eye, if blind, should be removed; if not blind, the same course should be pursued as suggested when the condition is that of sympathetic irritation in the second eye in other words, do not enucleate.
As regards medicinal agents, we possess nothing which exercises a specific influence for good in this disease. Atropin should be used, but always guardedly. Absolute rest and darkness are essential. Hot fomentations, such as have been described in the treatment of iritis, do good service; so also the various ways of applying dry heat. Calomel in small doses is certainly helpful. Injections of pilocarpin have been known to do good. The injection of one drop of a sublimate solution (1: 1000) has been strongly advocated by Abodes.
The influence of an operation is hurtful so long as there is present any evidence of an acute inflammation. The chief obstacle to vision is the opaque lens, and after all acute symptoms have disappeared Critchett suggests the following procedure: A fine needle is directed to the center of the opaque capsule, and the latter is pierced. Another needle is passed in from the opposite side, and by bringing the penetrating force of one needle to bear upon the other a small opening is made in the capsule. The points of the needles are then separated. In this way quite a rent is made. There is generally an escape of lens matter. Little or no reaction follows. An interval of several weeks is allowed to pass to permit the absorption of some lens substance, and then the operation is repeated, and so on, the operation being performed every time with two needles. Critchett and Story report cases where useful vision %vas obtained by this operation.
DISEASES OF THE CHOROID.
Congenital Anomalies of the Choroid. Coloboma of the choroid is a circumscribed, frequently half spherical shaped defect in the choroid and retina, as seen in Fig. I., Plate 3. It presents a brilliant white color (due to the exposed sclera) with the ophthalmoscope, and it will be observed that the surface of the coloboma is distinctly below the plane of the retina in other words, the surface is concave, and ridges and depressions can be seen upon it. Generally, two or three fine retinal vessels can be seen to dip at the edge of the coloboma, and then pass on over the surface of the latter. The coloboma usually begins a short distance from the optic nerve, or it may take in the papilla, and, assuming the shape described, pass downward and come to a stop at a certain distance from the ciliary body. It may reach a point so far forward that its anterior border can no longer be seen. The border of the coloboma is pigmented, and pigment spots are often to be found upon its surface. Coloboma of the choroid is generally associated with the same defect in the iris. Such eyes are sometimes microphthalmic. The retina, as well as the choroid, may be absent at the site of the coloboma, and only the sclera remain beneath. At other times the retina may be present, and covers the coloboma in its entire extent. Of course there is always a defect in the visual field corresponding to the location of the coloboma. According to Meyer, myopia, amblyopia, and accommodative asthenopia are often present.
White depressions of various sizes situated in the macular region are regarded by some authors as similar defects, and are spoken of as macular colobomata, while Lindsay Johnson describes them as the atrophied remains if nevoid growths in the choroid.
Coloboma of the choroid is due to incomplete closure of the ocular ti ssure and it is an affection which in a marked degree is transmissible by inheritance (see also page 192).
Albinism. This is a condition where there is either a partial or complete absence of pigment in the choroid. The affection is congenital. The pupil has a reddish luster, and is somewhat smaller than normal. The iris appears. reddish by transmitted light. This latter phenomenon is due to the fact that much of the light is not absorbed, owing to the lack of pigment. The vessels of the retina and choroid may be plainly seen with the ophthalmoscope. Photophobia is the rule in this condition, and a shady place is always grateful to such patients. Nystagmus, amblyopia, and high degrees of myopia and astigmatism are usually coincident conditions. The cells which usually contain the pigment are present, but the pigment itself is absent. The affection is hereditary. The treatment consists in measures to ameliorate the photophobia and the correction of the refractive error.
There is a condition in which the stroma of the choroid is richly pigmented, while the epithelium is lacking in pigment, and consequently is transparent. Under these circumstances the so called choroidal intervascular spaces exist, which look very dark, owing to the character of the stromapigment. This condition is sometimes seen in Negroes.
Hyperemia of the Choroid. This condition undoubtedly exists, but is questionable whether it can be diagnosticated. According to de Schweinitz, we may assume hyperemia of the choroid when the nerve head presents distinct redness, which is imperfectly differentiated from the unduly flannel red appearance of the surrounding choroid, or when the choroid, instead of exhibiting its usual red color, has changed into what has been denominated a ' woolly choroid," with faint dark areas in the periphery, indicating the interspaces between the choroidal vessels and more or less retinal striations surrounding the disk. The condition is ordinarily supposed to be due to 49 eye strain," and should be treated accordingly. Park glasses and complete rest should be ordered until the changes described have entirely disappeared, and then the error of refraction should be corrected.
Choroiditis. Inflammation of the choroid may be either non suppurative (commonly called exudative) or suppurative.
1. Exudative Choroiditis. Etiology. Thee most common cause is syphilis, both hereditary and acquired. Any profound disturbance in the nutrition, such as scrofula or anemia, may give rise to the same disease. Meyer mentions the fact that this form of the disease is sometimes found in women who suffer with menstrual disturbances or at the climacteric. Myopia cannot be said to cause choroiditis in the same sense as syphilis, for the changes in the former are more of the nature of degenerative changes than of true inflammatory ones, and are due to the stretching to which the posterior segment of the eyeball is exposed in myopia of very high grade.
Pathological Anatomy. The histological changes are usually sharply defined, and correspond to the ophthalmoscopic picture; that is to say, there is Do general involvement of the choroid except in cases of many years' standing. The vessels are frequently engorged, and round cell in ration is found near them. Small open spaces containing fibrin and hyaline in drops are often seen. Hemorrhages are occasionally observed. The pigmentcells are sometimes devoid of processes, and often have a proliferation of pigment. Later on the choroid becomes atrophied and fibrous, and the pigment clumps become scarcer and may disappear entirely. In those cases where the exudate has forced its way into the layer of rods and cones, this layer may be completely broken up.
The following interesting changes are mentioned by Schweigger as occurring in disseminated choroiditis: Little nodules are seen scattered through the stroma of the choroid, which consist of nucleated fibers and non pigmented cells. The surface of these nodules is at first covered with very black pigment epithelium, which gradually disappears from the center outward, so that we have the well known picture of a white area surrounded with a black ring. At points we have a proliferation of the pigmentepithelium. The new formed cells contain no pigment. When the process extends into the retina, we have an elongation of the radiating fibers, and they sometimes bend abruptly and are found bound fast to the choroid.
Symptoms. With the ophthalmoscope will be seen yellowish white spots scattered over the red fundus and lying under the blood vessels of the retina (recent choroiditis). As time goes on this yellowish color disappears, and gives way to white, which is an indication that the choroid has lost its pigment (atrophy) and that the sclera is exposed. Specks of pigment are often to be seen on these atrophic areas. Sometimes the exudates are very small, and are found either isolated or in groups, and located in various parts of the fundus (disseminated choroiditis). Dust like opacities and floating membranes in the vitreous body are common in exudative eboroiditis (Fig. 11. Plate 3).
Disturbances. in vision are always present, showing themselves in narrowing of the field and loss of visual acuity, though it is astonishing how good vision may be in cases where the ophthalmoscope shows an involvement of apparently the entire fundus. The patient complains of seeing specks floating before the eyes. Photophobia, metamorphopsia, and night blindness are present in a certain number of cases. The disturbances in vision arise partly from the opacities in the vitreous body, and partly from a functional disturbance of the retina, which is always to some extent involved.
In the earlier stages of disseminated choroiditis there is often a coincident dilatation of the retinal blood vessels, owing to the invo lvement of the retina. This variety of choroiditis is sometimes called syphilitic choroiditis (see page 419).
Again, in the vicinity of the optic nerve rather prominent foci of inflammation, composed of transparent, non pigmented tissue may be found; and at these points the retina is atrophic. These areas appear at first as deeply pigmented spots, having a bright yellowish center and surrounded by a red hyperemia ring. Later on these areas become flatter, are bordered with pigment, and traversed by choroidal vessels. This is areolar choroiditis (Forster). In both areolar and disseminated choroiditis the regions of the fundus between the diseased areas are usually sound in the earlier stages of the affection.
Sometimes the exudates are located chiefly in the macular region (central choroiditis, Fig. 229). The disturbance in visual acuity in this variety of the affection is very pronounced. While any of the causes mentioned above may give rise to central choroiditis, its most frequent cause is myopia of high grade. Among other special causes are contusions of the eyeball ; for instance, a blow which gives rise to rupture of the choroid will often be followed by choroidal changes in the macular region.
The macular region may be the seat of a large white patch, while the rest of the fundus is normal (senile areolar atrophy of the choroid).
Again, in the same locality may be found small white, glistening spots closely resembling the changes which are seen in albuminuric retinitis. Generally these changes are found in both eyes. They constitute the senile guttate choroiditis of Tay and Hutchinson. The white specks are due to colloid degeneration of the choroid (Fig. 230). Changes in the macular region, consisting of white plaques of various sizes and shapes, associated with atrophy of the choroid at the border of the disk, are often seen in high grades of myopia, and are spoken of as myopic choroiditis. The peculiar crescent shaped area at the disk is known as posterior staphyloma, and is to be attributed to the protrusion of the sclera backward.
Patches of choroidal atrophy may be found at any point in the fundus, and may result from various causes, as from the action of brilliant light or the glare of heat, or from the so called hemorrhagic choroiditis in young men (Hutchinson). These and other changes in the choroid which are typical of no special lesion are regarded as unclassified forms of choroiditis.
Diagnosis. It is certain that in the majority of cases there are changes in the retina, so this condition may be assumed to be present. It is very often a question, however, whether the exudates seen with the ophthalmoscope lie in the retina or the choroid. Retinal exudates are supposed to be more opaque, and to be bordered by fine radiating lines corresponding to the direction of the nerve fibers (Meyer). The blood vessels of the retina in refining are tortuous, and often disappear under the exudates, while the course of the retinal vessels may be plainly traced when the exudates lie in the choroid; and this rule also applies to the situation of pigment masses. Masses of pigment resembling bone corpuscles are always situated in the retina (Nettleship).
Prognosis. When atrophy of the choroid has taken place, the outlook is absolutely bad. Floating opacities in the vitreous body, as a rule, persist in spite of all treatment. As a general thing, the prognosis in choroiditis is unfavorable, and worse when the changes are prominent in the macular region. Of course the earlier the disease is recognized the more may be hoped for from treatment. Those cases clearly due to syphilis offer the best chances for improvement.
Treatment. Antisyphilitic treatment in certain cases is followed by improvement, and even by cure. Recurrences are very common. In cases where syphilis can be excluded the mercurials and iodid of potassium through their absorptive power do good service, and should be used. The application of six or eight leecbes or the artificial leech (Heurteloup) to the skin behind the mastoid process has been strongly recommended. Good results have been reported from the injection of .1 grain of muriate pilocarpin every other night. Cod liver oil and iron are specially indicated in children. The eyes should not be used for work, and dark glasses are advisable. Subconjunctival injections of bichlorid and cyanid of mercury have been recommended by Darier and others, but are of doubtful value.
2. Suppurative Choroiditis. As the Dame implies, this is an affection of the choroid suppurative in character, and one which rapidly involves the iris and ciliary body.
Etiology. The most frequent causes are injuries from penetrating foreign bodies. Suppurative choroiditis sometimes follows unsuccessful cataract operations. No matter what kind of instrument produces the wound, after all infection is responsible for the suppurative process. Sloughing ulcers of the cornea and the progress inward of the suppuration may be responsible for the affection.
The disease may result from endogamous infection that is to say, from the organism itself. In these cases septic substances form a focus of inflammation, get into the circulation, and are carried into the choroidal vessels, and here stop and form a septic embolus, which at once gives rise to the choroiditis (metastatic choroiditis ). This phenomenon is sometimes seen in the pyemia of the puerperal state. Suppurative choroiditis may follow cerebrospinal meningitis and typhus. Inflammation of the umbilical vein and thrombosis of the orbital veins have been known to cause the disease.
Amatomy. The choroid and retina are enormously thickened and infiltrated with round cells. In fact, in advanced stages the choroid and retina lose their identity almost entirely, and we simply find large areas made up of coagulated material and round cells, with here and there a clump of pigment granules. The exudate having found its way into the vitreous body, the latter is converted into a homogeneous mass of exudate. Round cell infiltration of the iris and ciliary body is seen with numerous hemorrhages and more or less change in the pigment epithelium, the latter changes manifesting themselves either in a breaking up or in an entire disappearance of the epithelium.
Symptoms. The lids are red and swollen, so much so that often they cannot be opened, and the orbital tissue is frequently so infiltrated as to interfere with the movements of the eyeball. The conjunctiva is intensely congested. often reaching the grade of chemosis. The cornea sooner or later becomes clouded, but before the media have lost their transparency one can see the characteristic yellowish reflex in the pupil, arising partly from the mass of exudate in the vitreous body and partly from the detached retina. Hypopyon and anterior synechie are usually present. The intraocular tension is elevated in the earlier stages, the pupil is dilated, and the anterior chamber shallow. Intense throbbing pain is felt in the orbit and brow, and sight is lost. Chills and fever are frequently present.
Diagnosis. Only one condition simulates the peculiar reflex seen in suppurative choroiditis, and that is glioma of the retina. Apart from the general history, there is this marked difference. In suppurative choroiditis the tension is always elevated in the stage when it is apt to be first seen, and this condition is followed soon by either lowered tension or by bursting of the eyeball. In glioma the tension in its early stages is normal, and increased tension does not make its appearance till the latter stages of the affection. The previous history of the case is probably the most reliable basis for a differential diagnosis (see also pages 400 and 494).
Prognosis. The outlook is absolutely bad. Loss of sight and shrinkage of the eyeball (phthisis bulbi) are the rule.
Treatment. It is not possible to put a stop to the process, so all that can be done is to relieve the suffering of the patient locally by hot applications, and internally by the administration of narcotics. Violent and persistent pain can be remedied by a free incision in the sclera. This may be found necessary in those cases of panophthalmitis where spontaneous rupture is slow in taking place.
As to the advisability of enucleation or evisceration in the acute stages of panophthalmitis, there is a difference of opinion. While a few cases of death have been reported after the enucleation, the risk is very slight, and it is by no means certain that the operation was responsible for the unhappy issue in those few cases. Meningitis has been reported after evisceration, and, indeed, where no operation was performed.
Tuberculosis of the Choroid. This condition was first described by Jager, and later by Manz, Busch, and Bouchut. The tubercles appear as small, round, slightly elevated, reddish or gray nodules, varying in size from 0.3 to 2.5 Dim. The spots are sometimes quite numerous, even as many as fifty being noticed, and they are distinguished from somewhat similar choroidal changes in that they are not surrounded with a border of pigment. These nodules are usually found in the vicinity of the optic nerve.
The little nodules on anatomical examination are seen to possess the typical structure of tubercles. A part of them sometimes undergoes caseous degeneration (Manz). Giant cells have been observed in them (Alt), and the tubercle bacillus has been demonstrated. According to Cohnheim, the affection forms one of the symptoms of acute general miliary tuberculosis, and it may aid in diagnosticating the constitutional disease.
Sometimes a solitary tubercle is observed, which grows like any other intraocular neoplasm, and finally breaks through the sclera. This condition is a rare one, and is usually associated with cerebral tuberculosis, and is affection peculiar to children. Treatment. Miliary tubercles demand no special treatment, but enucleation is the proper course to pursue in solitary tubercle in order to prevent a general infection.
Atrophy of the Eyeball, Atropby of the eyeball consists in a gradual diminution in the size of the eyeball, accompanied with diminished intraocular tension and altered shape. The change in the size and shape is to be attributed to the contraction of the exudates within the eyeball ex u dates which have resulted from the plastic irido cyclitis. Fuchs says that this condition differs from phthisis bulbi in that the latter affection is a much more rapid one, and results from the rupture of the eyeball and the evacuation of its contents. After panophthalmitis the eyeball often becomes as small as a hazelnut or even smaller, while in atrophy no such stage is commonly reached.
Essential Phthisis Bulbi (Ophthalmomalacia). This is a very rare affection in which there are lowered intraocular tension and diminution in the size of the eyeball without any assignable cause. Photophobia, neuralgic pains, myosis, and partial ptosis are sometimes present. The condition may last for several days, and then disappear without leaving any traces. It is supposed to be due to a lesion of the sympathetic. It may follow injury.
Rupture of the Choroid. Rupture of the choroid is caused by a powerful blow upon the eyeball. The blow has the effect of stretching the sclera. At first it is impossible to make out the exact nature of the trouble, owing to the extravasations in the vitreous body. As soon as the vitreous body becomes transparent one can see a long, bright, sickle shaped streak on the temporal side of the papilla, and with the concavity of the sickle directed toward the papilla. When first seen the streak is Yellowish in color, but it soon becomes white and has a pigmented border. Small spots of choroidal atrophy are frequently seen in the neighborhood of the rent, and these changes may invade the macular region. It is certain that the retina and sclera are both injured. The retinal vessels will generally be seen passing over the injured point, except in those cases where the retina itself participates in the rupture. No good reason has been advanced as to why the posterior part of the choroid is disposed to rupture. We may have the rupture occurring in one spot or in several spots (Plate 3, Fig. III.).
The vision at first is almost extinguished, but after the blood in the vitreous clears away good vision is often restored. Cases are reported by Knapp and Saemisch where central visual acuity returned to almost the normal standard. As a consequence of rupture of the choroid, retinal detachment, glaucoma, and optic nerve atrophy have been observed. Traumatic cataract and dislocation of the lens are also complications (see page 364). The treatment consists in a compress bandage and atropin. It is doubtful whether the subsequent use of strychnia or iodid of potassium does good.
Detachment of the Choroid. This is an exceedingly rare condition. One observes a round looking mass projecting into the vitreous body. The surface of this mass is perfectly smooth, and the retinal vessels can be seen upon it. The color of the protuberance is sometimes yellowish, with pigmented areas here and there about it. Meyer says it may be distinguished from detachment of the retina because it does not move with every movement of the eyeball. Detachment of the retina is usually present. The tension in detachment of the choroid is always diminished. Marshall thinks that the following factors are necessary to cause this condition: hyalitis with shrinking; choroido retinitis leading to adhesions and serous exudation between the choroid and sclerotic. Risley reports detachment of the choroid caused by the concussion at the discharge of a gun.'
Ossification of the Choroid. This is not infrequently found in shrunken eyes where sight has been lost many years previously. A thin Shell of bone is found in the posterior part of the eyeball, with a small bole in its middle for the passage of the optic nerve; or sometimes simply a spicule is found. The mass possesses all the histological characteristics of bone anywhere else in the body. The eyeball is often painful to the touch, and it may give rise to sympathetic irritation; so enucleation is always advisable. Calcareous degeneration is also common in eyes of this character.
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