DEPARTMENT OF OPHTHALMOLOGY (continued 2)

Ulcer of the Cornea

Inflammation of the cornea sets in from some cause. There is an infiltrate into the substantia propria. A spot becomes cloudy and the surface over it becomes dull; at this point the epithelium breaks down or exfoliates and the loss of substance in the parenchyma is the beginning of an ulcer.

Cause.—The cause may be constitutional or local. The causes usually thought of from the medical standpoint may be noted in such books as “Diseases of the Eye” by De Schweinitz or Weeks. I wish especially to call attention to the fact that there is frequently a primary and underlying cause of corneal ulcers not mentioned in any medical texts, i. e. the osteopathic lesion. By this I mean more than the spinal lesion although the subluxation lesions that result from the occiput to the fourth dorsal are of most importance. Any tension or change of tissue in the cervical region that may interfere with perfect freedom of circulation of blood to the tracts and centers in the cord, is to be considered. The osteopath of course should take into consideration all causes primary and secondary and govern himself accordingly.

Symptoms and Course.—There is a gray area surrounding the ulcer at first, also the floor is grayish in color. In this condition it is known as a progressive ulcer or a foul or unclean ulcer. This cloudiness or gray area may increase in size and the ulcer keep spreading, or it may go deeper even to perforation of the cornea.

Some ulcers advance or spread on one side and heal on the opposite side so that they creep along on the cornea—these are the so-called serpiginous ulcers.

With corneal ulcers there is irritation, pain, photophobia and increased lachrymation. There is usually some ciliary injection which is an indication of involvement of the iris and ciliary body. If iritis occurs there is contraction of the pupil with slow reaction. Hypopyon may develop. With iritis and the exudate there is likely to be adhesions between the iris and the lens known as posterior synechia.

A few corneal ulcers are asthenic and do not have irritative symptoms and yet are dangerous.

When the ulcer begins to heal it is called retrogressive. Dead tissue is cast off; other tissue becomes transparent from resorption. We have a clean ulcer. Symptoms disappear and cicatrization begins. Vessels extend to the ulcers and soon it is leveled up with the corneal surface. Cicatrization may leave it slightly below the corneal level or above it.

If there should be perforation of the cornea from the ulcer there may be complications, e. g. keratocele, loss of aqueous, dislocation and expulsion of the lens, intra-ocular hemorrhage, flattening of the cornea, fistula of the cornea, glaucoma, intra-ocular suppuration, prolapse of the iris into the opening, etc. These complications and sequelæ that occur occasionally will not be considered here.

After healing is complete by cicatrization there is opacity of the cornea in proportion to the depth and size of the ulcer. In months and years of time there is some clearing of the opacity so that small superficial opacities may become invisible.

Treatment of Corneal Ulcers.—Most ulcers of the cornea are quite amenable to proper treatment and the prognosis is favorable. Neglect or wrong treatment is very dangerous. The treatment is local and constitutional. Often the ulcer is kept going by unwholesome constitutional conditions.

Local Treatment.—This varies according to the stage of the ulcer, whether progressive or retrogressive. In a progressive or foul ulcer if due to trauma any foreign bodies should be removed. If the ulcer is a result of pathology of the conjunctiva it is of primary importance to treat the conjunctival condition.

In mild cases of ulcer a dressing over the eye with atropine ½% to keep the pupil dilated is sufficient local treatment. The bandage protects the eye from bright light and other environment and the atropine puts the iris and ciliary body at rest preventing complications and giving nature her best chance to work.

If the ulcer is rapidly progressive, warm compresses an hour or two a day are good; iodoform sprinkled on the ulcer or actual cautery may be used. In the retrogressive stage (clean ulcer) healing has begun and we desire to get as near as possible a resistant transparent cicatrix. Yellow oxide ointment is useful at this stage.

Osteopathic.—The local measures just mentioned are not incompatible with osteopathic theory or practice. They are merely adjunctive in getting nature’s reaction toward normalization, as also are hot and cold applications. Osteopathy comes in now in a most important and fundamental way with the constitutional and specific lesion treatment. The bulbo-spino-sympathetic-ciliary arc has been mentioned and explained. Through this important nerve connection with the eye, profound and wholesome effects on the eye may be gotten by osteopathic treatment. Frequently lesions of the occiput, cervicals and upper dorsals will affect the integrity of the ocular structures through disturbances of nerve and blood supply.

The stomach, bowels, liver and kidneys should be carefully noted in corneal ulcers. Poor circulation, indigestion, constipation and auto-intoxication may have an important bearing on the recovery of the ulcer.

Xerosis or Keratomalacia

This is a disease of the eye in children due to insufficient nutrition of the cornea. Hereditary influences, depleting diseases and lesions affecting the trophic nerves to the eye are causes.

Treatment consists of building up the nourishment of the child, correction of lesions and careful dieting. Hot applications to the palpebral region helps to bring the blood supply to the eye for local effects.

Keratitis Neuroparalytica

This disease is due to a paralysis of the 5th cranial nerve. The cornea becomes slightly cloudy. The epithelium gradually sloughs away. An ulcer may or may not form. Pain and lachrymation are absent because of paralysis of the trigeminus. There is usually ciliary injection.

Treatment.—The most important treatment for this unfortunate condition is manipulation to restore the integrity of the 5th cranial nerve and the blood supply to the eye. Cervical, spinal, nasal, nasopharynx treatment should be given. Spring the inferior maxilla.

A drop of atropine (1%) should be used locally because of the ciliary injection. Warm compresses used locally will help. The healing usually leaves some opacity of the cornea. Keep the eye bandaged to protect the cornea.

Pannus

This form of keratitis is superficial and is characterized by the formation of blood vessels in the cornea. It is caused by some irritative influence. Most often it is a complication of trachoma.

If the irritation can be removed the vascularity gradually recedes, leaving a clear cornea unless the deeper structures of the cornea have been involved.

Phlyctenular Keratitis

This disease is an involvement of the cornea with an eczematous process similar to phlyctenular conjunctivitis. There is more likely to be ciliary injection and iritis, in which case atropine should be used. The treatment is the same otherwise as for phlyctenular conjunctivitis.

Parenchymatous or Interstitial Keratitis

This is shown by a diffuse inflammatory infiltration of the substantia propria of the cornea. Part or whole of the cornea of one or both eyes may be involved. Very fine blood vessels may invade the deep structures of the cornea.

Cause.—Syphilis, tuberculosis, rheumatism, diabetes and rachitis are systemic diseases found back of this trouble.

Symptoms.—Irritation, lachrymation, photophobia with ciliary injection are the chief symptoms.

Treatment must be local and constitutional.

Locally atropine should be used. Dark glasses should be worn or the patient must be kept in a dark room. Treatment to the trigeminal nerve and tissues of the orbit should be given.

Constitutional treatment should be spinal with the idea of arousing all the forces of the body to greater activity. Careful dieting should be followed according to indications.

The infiltration and blood vessels will ultimately disappear. Sometimes enough may remain to cloud the vision.

Diseases of the Iris and Ciliary Body

The iris and ciliary body have the same blood and nerve supply. That is, they are supplied by the same set of vessels and nerves. For this reason it is practically impossible to have an iritis absolutely independent of a cyclitis or some inflammation of the ciliary body. If the iris is the primary seat of the trouble there are certain symptoms that may indicate such a state. However, when we are treating the iris or diagnosing conditions of the iris we must remember that the ciliary body is very likely more or less involved and may be the primary seat of the trouble.

In iritis there are some symptoms which are caused from the hyperemic condition of the eye, such as a slight change in color. The pupil becomes rather inactive, there is some ciliary injection with photophobia, lacrymation and pain. In case of an exudate in the iris there may be thickening, and the exudate in the anterior chamber of the eye will form a hypopyon. Sometimes the small vessels will break and there will be a little bleeding which will be mixed with the debris in the bottom of the anterior chamber. This is known as hyphemia. There are likely to be adhesions between the iris and the anterior capsule of the lens known as posterior synechia. The pupil is more or less irregular. If atropine is dropped into the eye to dilate the pupil, parts of the edge of the pupil will be adhered while the other parts dilate making it very irregular.

In case of cyclitis there is an exudate from the ciliary body into the posterior chamber. This may cause a total adherence of the iris to the crystalline lens. With the ophthalmoscope, opacities in the vitreous may be noticed. These are exudates. The tension of the eye is liable to increase a little at first but as the exudates absorb there is more or less softening. Vision is low. Also in cyclitis there is ciliary injection, photophobia, lacrymation and pain, similar to that of iritis. Pressure on the eye ball will reveal a very tender condition around the sclerocorneal junction or over the area of ciliary injection.

The causes of iritis, cyclitis or iridocyclitis frequently are systemic conditions and infection such as syphilis, rheumatism, gonorrhea, tuberculosis, infectious diseases and metabolic changes, it may be of traumatic origin or sympathetic. Fuchs says “There are many cases of iritis for which no cause can be discovered and therefore which cannot be placed under these causes.” We agree with him and advance the theory of cervical and upper dorsal lesions or trouble in the sinuses, nose, nasopharynx or throat. No doubt osteopathy can throw some important light on the causes of diseases of the iris and ciliary body. The nose and throat should be examined in all these cases.

Treatment.—Atropine must be used in the sore eye to put the iris and ciliary body at rest and dilate the pupil to draw it back from the lens so that adhesions may not form. Warm compresses will give much comfort. Sweating should be brought about. All fluid should be reduced to a minimum. Diet should be very moderate and the bowels kept unusually free. The eye should be protected by dark goggles. Thorough treatment of the neck and upper dorsal region with attention to the nose and throat should be given. Constitutional treatment should be given according to the indications mentioned under causes. If annular synechia or total posterior synechia form or there is atrophy of the eyeball operative work may be needed. Also for injuries, tumors, anomalies and so forth of the iris see the latest medical works on this subject.

Diseases of the Choroid

The choroid is the vascular tunic of the eye. With the iris and ciliary body it forms the uvea. The iris and ciliary body are rich in nerve terminals and when inflamed; pain is a prominent symptom. The choroid has no sensory nerve terminals. When it is involved alone; pain is not present however severe the pathology. Embryologically Descemet’s membrane is a part of the uvea. When the uveal tract is diseased we frequently note symptoms of a descemetitis as a turbidity of the anterior chamber and spots on Descemet’s membrane. When one part of the uvea is inflamed the tendency is to pass to the other parts because of the intimate blood supply.

Choroiditis

There are many forms of choroiditis given by writers according to the clinical picture and the pathology.

Symptoms.—No pain is experienced unless there are complications. Vision is altered in some degree. The use of the ophthalmoscope may reveal opacities in the vitreous. Pigmentation spots and exudation may be noted in the fundus. In disseminated choroiditis spots of exudate appear in the fundus which go on to atrophy, leaving irregular circular light patches.

Treatment.—In all forms of choroiditis careful diagnosis of constitutional conditions should be made and treatment given according to indications.

Nasopharynx and orbital treatment as outlined under manipulation for diseases of the eye should be given.

Rest and protect the eyes. Secure free elimination.

Panophthalmitis

By injury or otherwise pathogenic germs are introduced into the eye. The trouble begins as a suppurative choroiditis and rapidly spreads to all the eye structures. The vitreous chamber becomes filled with pus.

Symptoms.—Pain is severe and sight is lost early. The conjunctiva and lids are much swollen. There is a mucopurulent discharge. The cornea becomes gray and may slough. In about two weeks the inflammation subsides and the globe passes into atrophy.

Treatment.—Elimination must be thorough. Spinal treatment for keeping up strength. Cervical, upper dorsal and nasopharynx treatment for the eye. Moist hot compresses to the eye. Operation, incision for drainage, or evisceration may have to be performed.

Sympathetic Ophthalmia

The other eye may become inflamed by the process from the panophthalmitis passing around through the circulation or the continuous structures. All symptoms of a general inflammation appear and vision gradually diminishes.

Treatment.—In panophthalmitis of one eye always watch the other eye closely. If it becomes irritable or shows any signs of being affected the diseased eye should be promptly removed, especially if vision is lost in that eye. If no irritation occurs, continued conservative treatment of the panophthalmitis may result in a subsidence of the disease without the well eye becoming affected.

Sympathetic inflammation rarely develops earlier than a month after injury to the exciting eye. Sooner than that or even a few minutes after injury there may be some signs of sympathetic irritation and the symptoms continue with no evidence except a slight circumcorneal injection. It should be treated like iritis. A thorough toning of the system by spinal treatment should be given. Order a limited diet. Secure free elimination.

Glaucoma

Glaucoma is essentially an increase in the intra-ocular pressure. All other symptoms of the trouble may be traced to this condition.

In Primary Glaucoma the increase in pressure sets in without any discoverable antecedent disease of the eye.

In Secondary Glaucoma the increase in pressure is due to some other disease of the eye. It is a symptom, a complication or accessory and is confined to the eye diseased.

Primary glaucoma affects both eyes, but not always at the same time. Fuchs says primary glaucoma constitutes about 1% of all eye diseases. It is often mistaken for iritis or iridocyclitis and treated with atropine which is contraindicated. It may be regarded as beginning cataract and time lost in expecting it to become ripe. These delays and wrong treatment have caused much blindness.

Palpation with the finger or the use of the tonometer may readily detect any increase in tension. A correct diagnosis must be made early and proper treatment instituted if vision is to be saved.

Primary glaucoma may or may not have signs of inflammation. If the tension rises suddenly inflammatory symptoms develop (acute) while if the increase in tension develops gradually these symptoms are lacking (simple).

Acute primary glaucoma—Symptoms.—First stage, rise in tension, vision obscured, sees a colored ring around lights, cornea dull, pupil dilated and sluggish, some ciliary injection. The attack may clear up for a day or for weeks. Gradually the symptoms become permanent after repeated attacks. Second stage, when the attack comes there is much pain, visual power fails rapidly, may be edema of the lids and chemosis of the conjunctiva, all symptoms become much exaggerated, the cornea becomes cloudy. After a violent attack the vision is more or less permanently damaged. Third stage, after many attacks the optic nerve becomes excavated and atrophy takes place.

Simple Primary Glaucoma

Symptoms.—Tension comes gradually; no inflammatory signs; pupil somewhat dilated and sluggish, the cornea may look slightly smoky. With the ophthalmoscope a cupped disc may be noted. There is gradual diminution of sight, which begins by contraction of the field.

There are many theories advanced as to the cause of intra-ocular tension in glaucoma. (Fuchs, Weeks, De Schweinitz).

Treatment.—Eserine is used instead of atropine. The object is to contract the pupil and draw it away from the side wall of the eye ball so the sinus (Schlemm’s canal) and the pectinate ligament (the filtering angle) may become free. The good effect of this is more marked in inflammatory glaucoma. In simple primary glaucoma miotics do little good.

Reports from osteopathic treatment of this condition have been favorable in a number of cases. Careful manipulation of the structures of the orbit with the finger or with Dr. Ruddy’s third finger eye instrument is good in restoring better circulation of the lymph and blood. Special attention to the venous drainage should be given. Treat the points of the fifth nerve, the nasopharynx and cervical region, spring the jaw. Treat second dorsal.

Have the patient avoid strong emotions or excitement. Keep the bowels free and use only a very bland diet.

Iridectomy is considered the best operation in glaucoma.

In the treatment of secondary glaucoma the other diseases or complications must be considered in conjunction with the foregoing treatment.

Diseases of the Lens Opacities or Cataract

Symptoms.—Beginning opacities can best be recognized with the ophthalmoscope. Advance opacities can be seen at a glance with the naked eye.

Vision is disturbed according to degree and location of the opacity. If the opacity is in the center of the lens and the periphery is transparent they see better when the pupil is dilated. When the opacities are in the periphery of the lens they see better by day. Muscæ volitantes and polyopia are present until increasing opacity closes up all clear areas shutting out these visual perversions.

There are many clinical varieties of cataracts which may be studied in works on ophthalmology.

Causes.—Some interference with the nutrition of the lens accounts for the condition. Heredity is supposed to play a part in some cataracts. Rickets, convulsions, traumatism, old age, some drugs (ergot), inflammation of iris, ciliary body and choroid are given as causes. Cervical and upper dorsal lesions and disease of the throat, nasopharynx and nose will interfere with perfect circulation and drainage of the orbit, and may well have much to do with many idiopathic cataracts.

Treatment.—Many cases have been reported cured by osteopathic measures. Correct lesions and treat to establish free nerve force and circulation of blood and lymph to the orbit. Manipulation of the orbital tissues and mild vibration of the bulb are measures of value. More hope may be held in symptomatic, toxic, secondary and progressive cataracts. The process may be stopped and in many cases there is hope of a clearing.

Diseases of the Retina

The retina lines the back part of the eye ball. It comes forward to the ora serrata. It consists of ten layers which have been demonstrated microscopically. One layer of it passes over the ciliary body and back part of the iris to the pupil. The fibers of the optic nerve spread out over the retina. The point of entrance of the optic nerve is the papilla. It is to the inner side of the posterior pole of the eye. The retinal vessels emanate there. The macula lutea is the yellow sensitive spot at the posterior pole of the eye. The fovea is the center of the macula. The rods and cones constitute the external layer of the retina. This layer is the light perceiving stratum. For vision to be perfect all the other layers must be perfectly transparent. The visual purple is a chemical substance in the rods that gives the retina a purplish-red color. The light shining into the eye forms images which are converted into nervous stimuli by chemical action of the visual purple and by physical changes and fibrillations in the rods and cones.

Retinitis

Symptoms.—The ophthalmoscope must be used in diagnosis. There is at first cloudiness of the retina; the outlines of the papilla become indistinct. We may note light patches of exudates. The vessels are more tortuous and often there are hemorrhagic spots. Opacities in the vitreous due to the exudate may be seen. Vision is disturbed in proportion to the inflammation. Weeks or months are required for recovery. Atrophy may set in and cause blindness.

Cause.—Many general diseases are found back of this trouble, e. g. albuminuria, diabetes, leukemia, syphilis, gout and arteriosclerosis. Idiopathic cases occur with none of these diseases present, which gives a field for osteopathic research.

Treatment should be directed against the general disease when present. For local effects treatment should be given to all the centers and localities that affect the trophism, nerve supply and circulation to the eye. Protect the eye by dark glass or confinement to a dark room and complete rest. Keep the bowels free and produce diaphoresis.

Optic Neuritis

This disease when manifest in the eye ball is called papillitis. If back of the bulb it is retrobulbar neuritis.

Symptoms of papillitis.—Pupils are dilated and sight diminishes. The color of the papilla is altered to a white, reddish or gray and may show extravasation of blood. The papilla is swollen (choked disc), the arteries are thin and the veins are engorged. It takes months for the inflammation to clear. Atrophy is likely to occur.

Causes.—Brain diseases are the most frequent cause, e. g. tumors. Syphilis, febrile diseases, nutritive disturbances, lead poisoning, heredity and growths in the orbit are cited as causes.

Symptoms of Retrobulbar Neuritis.—There is little or no change in the papilla. The diagnosis must be made mostly from the way the vision is affected. The rule is a central scotoma in the field of vision. The first colors to disappear are red and green. In the acute form there is quick disturbance of vision. The eye looks normal outside and shows practically no change inside.

Cause.—Toxemia, cold, influenza; nasal, nasopharyngeal and sinus disease (ethmoids), and infectious diseases are causes. Idiopathic inflammation of the optic nerve is noted by most oculists. Here the profound effects of spinal lesions upon the eye adds some important light.

Treatment of Papillitis and Retrobulbar Neuritis.—In each individual case the treatment requires consideration of the causal factor. There may be required constitutional treatment in many cases. In others the cause may be found in the nose, nasopharynx, or spine. Effort should be made to remove the lesion in each case. Diaphoresis will aid in acute stages.

Atrophy of the Optic Nerve

There are many causes for this condition such as optic neuritis, meningitis, acute infectious diseases, locomotor ataxia, arteriosclerosis, nasal disease, syphilis, traumatism, alcoholism, exposure, embolism of the central retinal artery, diabetes and poisoning. Diagnosis must determine the original cause.

Treatment.—I have mentioned conditions in the nose as frequently accounting for various eye troubles. If these atrophies of the optic nerve can be gotten early, many of them will be influenced very favorably by osteopathic treatment. Spinal treatment to direct the circulation to the area of the orbit at the base of the brain is beneficial. Regulation of the patient’s diet, habits, methods of living and so forth is important. Excessive mental strain, excessive sexual intercourse and stresses of every kind should be prohibited. Special treatment should then be given according to the causal factors entering into the case.

Eye Strain and Its Reflexes

For the subject of refraction and refractive errors such as the different forms of hypermetropia, myopia and astigmatism the reader is referred to the many excellent works on ophthalmology which cover these subjects quite thoroughly. They are only used here in the relation to eye strain and its reflexes. The osteopathic logic here given should be combined with a reading of the refractive errors in such works as Fuchs, Weeks, De Schweinitz and others.

Asthenopia

Eye strain, weak sight or asthenopia embraces the group of symptoms dependent upon fatigue of the ciliary muscles or of the extraocular muscles.

There are three varieties of asthenopia. (1) Retinal or nervous, (2) muscular and (3) accommodative.

The symptoms are headache—frontal, fronto-temporal or fronto-occipital. It may extend into the neck between the shoulders. Eye balls may be tender, diplopia at times, may be photophobia, lachrymation, congestion of the eye, itching and burning of the lids.

Accommodative Asthenopia.—In this form the ciliary muscle is fatigued. The cause is usually overuse of the eye when hyperopia and astigmatism exist; sometimes in myopia or presbyopia.

Treatment.—In this form the treatment is the proper fitting of glasses and improvement of the general health.

Muscular Asthenopia is due to tiring of the extraocular muscles, usually the internal rectus. This may result in a phoria or a non-paralytic squint.

Ametropia may exist but asthenopia may come even in emmetropia due to overuse of the eye.

Treatment.—Correct ametropia if present, with glasses. Exercise the weakened muscle. Correct the nerve supply to the weak muscle. Treat cervical and upper dorsal. Manipulate tissues of the orbit. Spring the jaw. Correct any nose and throat pathology.

Nervous, Neurasthenic or Reflex Asthenopia.—The cause is supposed to be some functional disorder, more often found in females. May be due to too dim or too bright light, overuse of the eyes. Hysteria may follow ametropia.

Treatment.—Often the treatment is troublesome and the case is very obstinate according to old school methods. Rest, hygiene, general health and habits are looked after. The cause must be found or the treatment cannot be specific.

These are the different forms of eye strain as ordinarily classified. Now as we study the reflex symptoms from these and attempt to trace out the reflexes from an osteopathic point of view, we may find some more definite causes of these conditions and consequently some methods of treatment not found in standard text books might naturally suggest themselves.

Reflex symptoms that have been traced to eye strain by ophthalmologists are as follows:

Constipation, indigestion, heartburn, nausea, vomiting, nervous attacks, fear of impending calamity, irritability, despondency, insomnia, restless sleep, epilepsy, nervous twitchings and enuresis. All these symptoms have been seen to disappear after eye strain was corrected. There is no absolute way of proving that all these symptoms have existed because of eye strain. The existence and disappearance of some of them at the time of treatment for eye strain may be a coincidence. It is evident that eye strain in varying degrees may produce a train of symptoms similar to many above mentioned.

A patient, nervous, anxious, uneasy, and despondent, constipated, and having some indigestion, showed on examination contractures and tenderness at the third dorsal. It was found he was suffering from eye strain from overuse of glasses that were too strong for him. The eyes were refitted. He was wearing a

(R)+4.50 D. S. = +.50 cyl. Ax. 180.

(L)+4.50 D. S. = +.50 cyl. Ax. 90

for close work and a (R)+2.00 D. S. = +.50 cyl. Ax. 180

(L)+2.50 D. S. = +.25 cyl. Ax. 90

for distance. The new glasses were—Reading—

(R)+3.00 D. S. = +.25 cyl. Ax. 180

(L)+3.00 D. S. = +.25 cyl. Ax. 180

Distance:

(R) + 1.50 D. S. = +.25 cyl. Ax. 180

(L) + 1.50 D. S. = +.25 cyl. Ax. 180

He was fitted two years previously. At that time the stronger glasses were correct. Eyes change more or less constantly, especially between the ages thirty-five to fifty-five years. When glasses are fitted, a weak ciliary muscle after a rest may become stronger and allow weaker glasses to be worn.

If a young person is fitted for myopia, in a few years he may discard his glasses as presbyopia develops. A person fitted correctly, who has a strong ciliary muscle may not be able for awhile to see as well with the glasses as without them. After they are worn awhile the ciliary muscle will cease its efforts to accommodate so much and the glasses give the desired effect. In some cases the doctor’s reputation to fit glasses properly may suffer at the hands of such people who sometimes refuse to take glasses, or after getting them refuse to wear them.

In the case of the man just mentioned a refitting quieted the nervous symptoms—he became more cheerful and ceased to worry. Indigestion and constipation improved. The soreness and contractures were overcome in a few treatments.

Now let us ask the question, why is it that eye strain will cause nausea and vomiting? Also why will indigestion affect the eyes by causing “spools” in the vision?

A little osteopathic logic, based as it always is or should be, upon anatomy and physiology, may throw some light on this subject. No doubt every one of us has demonstrated many times clinically that indigestion from overeating will cause soreness and contractures at the third and fourth dorsal, the nerve center in the spine for the stomach.

The reflexes between the viscera and the eye are complex and difficult to follow. In giving the probable course of the nerve reflexes from the optic nerve to the third nerve Dr. Louisa Burns suggests the following: “The nerve elements of the retina start the impulse; it passes over that portion of the optic nerves which enter the anterior quadrigeminates, the cells of the quadrigeminates where the impulses are coordinated, then by axons of these cells to the lateral or viscero-motor nucleus of the third nerve, thence to the cells of the ciliary ganglion, and by the non-medulated (sympathetic) fibers of these, the short ciliary nerves to the non-striated muscles concerned, viz: the ciliary muscle, some fibers of the levator palpebral and the sphincter of the iris.”

The third nerve arises in the floor of the aqueduct of Sylvius from two nuclei; a lateral nucleus which is a viscero-motor group of nerve cells, and a central nucleus or a somato-motor group of cells. The somato-motor nucleus supplies all the extrinsic muscles of the eye except the external rectus and superior oblique which are supplied by the sixth and fourth respectively. The nasal branch of the ophthalmic division of the 5th sends fibers to the ciliary muscle. Association fibers connect the nuclei of the 3rd, 4th, 6th and 7th. The evidence is in favor of the 10th or pneumogastric having such association fibers.

We noted four places in the brain to which the optic tracts go before the radiations reached the center of sight in the occipital lobe. If we cannot follow all the reflexes through the brain and cord at least with the facts we have it is not difficult to imagine abnormal impulses coming over the third nerve from a straining of the ciliary nucleus, thence over viscero-motor fibers in the lateral horn of the cord, over the white ramicommunicantes, through the sympathetic ganglia, over the splanchnics to the stomach, producing abnormal peristalsis, nausea and vomiting. In turn we would have the somato-motor nerves to the muscles affected as before described, contraction and congestion of muscles of the spine.

When we have patients consult us and describe a train of symptoms like nausea, vomiting, nervousness, frontal and occipital headache, we should have eye strain in mind and inquire for lachrymation, photophobia, itching and burning lids and congestion of the eye. Any of these things should make us think of testing for ametropia in its various refractive errors, as well as a careful spinal and a nose and throat examination. General physical and laboratory diagnosis should not be neglected.

References

Fuchs’s Text Book of Ophthalmology, Duane.

Headaches and Eye Disorders of Nasal Origin, Sluder.

External Diseases of the Eye, Greeff.

Vol. III Practical Medicine Series: The Eye, Ear, Nose and Throat by Casey A. Wood, Albert H. Andrews, Geo. E. Shambaugh.

Diseases of the Eye, Weeks.

Diseases of the Eye, Ear, Nose and Throat, Posy and Wright.

Diseases of the Eye, De Schweinitz.

Diseases of the Eye, May.

Text Book of Ophthalmology, Roemer and Foster.

Diseases of the Eye, Jackson.

Ophthalmic Surgery, Meller.