DEPARTMENT OF OPHTHALMOLOGY
Reading edition
By C. C. Reid
It is the desire to make this discussion on the eye the most useful possible to the whole profession. Let it be plainly understood that there is no effort to cover every phase of eye pathology but to elaborate eye diseases and therapeutics strictly from the standpoint of osteopathy. There are many very elaborate and extensive text books and even encyclopediæ written on the eye by the medical profession. The world of ophthalmic literature is extensive and profound. Just so are the elaborations on the general field of medicine. Such things as hereditary influences, congenital deformities, amblyopias, albinism, coloboma and the field of ophthalmic surgery does not concern us at the present time in an osteopathic text book. This department is dedicated to a scientific development of ophthalmic therapeutics along osteopathic lines of thought. Some things in the therapeutics of the eye concern all schools alike. For instance, proper cleanliness and antiseptic precautions in regard to the eye, dietetics, hygiene and the care of the general health. The same anatomy and many of the same methods of examination and diagnosis obtain in all schools. It is the intention to go into the opthhalmic therapeutic field in these discussions where osteopathy has a different outlook with a definite distinct reform to offer in the viewpoint of the anatomy, methods of diagnosis and the system of treatment.
How to Examine an Eye
It has been said that one should be a good general man in order to be a competent specialist. This is especially true in regard to ophthalmic therapeutics. Many systemic diseases have eye symptoms and pathology. The same blood and lymph that nourishes and bathes different parts of the body, also circulates in the structures of the eye. In the examination of the eye, heredity, occupation and environment are to be taken into consideration. Osteopathic lesions may exist from falls, strains, twists, blows, colds and exposure and impair the integrity of the metabolic processes of the eye through the nerve connections and blood supply and lay the foundation for a great variety of eye diseases. With these lesions existing about the neck and upper dorsal, it is only required to have some insignificant local irritant to start symptoms and cause pathology apparently out of all proportion to the etiology. It is important then that one understand the nerve centers and reflexes and the osteopathic logic underlying these conditions or else he must frequently work without a satisfactory explanation of the etiology and consequently be more or less unscientific in his treatment.
The eye examination should consist of the case history, the family history, inspection, osteopathic examination, especially from the fourth dorsal vertebra to the occiput and especial examination of the eye by inspection and other methods.
1. The Case History.—Thoroughness of the doctor, or the lack of it, will be readily displayed at this point. Every little thing, as far as possible, that has a bearing on the case should be observed and uncovered in the case history. The physician should want to know every fact that helps him to better understand his case. Patience in hearing the history will often be of great assistance. It gives light on the physical and mental condition of the patient. Much can be gained by being careful and attentive. Notice carefully what he emphasizes and what he thinks is the most important. Inquire in regard to headaches, nervous symptoms, previous eye trouble and past illnesses. Get a venereal history if present, as many eye diseases are complicated or caused by syphilis or gonorrhea.
2. The Family History.—Inquire as to blindness in the family and about the age it occurred, if any. Get a venereal history if possible.
3. Inspection.—Much inspection can go on while the history is being taken. Observe the countenance, whether there is strabismus or frowning due to eye strain, photophobia as suggested by the effort to avoid the light; note symmetry. Look closely at the lashes, lids, conjunctiva, cornea and iris. Note any scales or crusts on the lids at the root of the lashes. Turn the lids for further inspection. Note the size and relation of the eyes. Exophthalmos may be due to an enlarged globe in high myopia, to Graves’ disease, orbital tumor and paralysis of the extrinsic muscles, or staphyloma. In blepharospasm there may be a corneal ulcer or a rupture of the eyeball. An exact examination must be made at the first visit in order for a diagnosis to institute the best treatment possible. Study the conjunctival sac for congestions, hypertrophy, swelling, tumors, foreign bodies, trachoma bodies and secretions. In all forms of conjunctivitis the congestion is most marked in the fornix and decreases toward the sclerocorneal junction. In iritis and cyclitis there is a circumcorneal injection, a pink or red color radiating from the cornea. Note any corneal pathology in the way of ulcers or abrasions and foreign bodies. Compare the tension of the eyes.
4. The Osteopathic Examination of the Eye.—This heading is put here in order to show what osteopathy has to offer that is distinct as belonging to our system and not practiced by any other school. Osteopathic research so far has shown that osteopathic science has much to offer on etiology and diagnosis and treatment in eye diseases. The case history, family history and inspection should require but a few minutes but they are essential to a proper examination and may aid us in what to expect osteopathically. Weak nerves will cause asthenopia. A broken arch, an innominate lesion or a slipped axis may cause weak nerves. The osteopathic eye examination then should consider the whole mechanism of the body. In case glasses are being worn for asthenopia they may readily be made unnecessary by osteopathic treatment in the correction of the lesions and building up the system. Some time ago some parents sent their daughter to me to have her eyes fitted for glasses. They stated that she had been to different doctors and opticians and no one had ever given satisfaction. They said she was all right every other way if her eyes were properly fitted with glasses. They did not want her examined or treated otherwise because she would be well every other way with correct glasses. Her vision was right eye 5-20, left eye 5-15 or about one fourth vision in each eye. A plus .87 diopter sphere combined with a plus 3 diopter cylinder in axis 90 gave her perfectly normal 5-5 vision in each eye. This gave her perfect satisfaction until she started to school in September, a couple of months later. Before the end of the first month she was having trouble with her eyes and was again sent to me by her parents. Her vision was reduced to 6-15 in each eye with her glasses on. She wondered and no doubt the parents did, if it was not another case of a misfit in glasses similar to all her previous experiences. This time I insisted upon a thorough physical examination against all protest. The following lesions were discovered: the left innominate was up and back or tilted posteriorly, first lumbar anterior and to the right, sixth and first dorsals to the right. The case was not refracted again. I took particular care the first time and I was quite sure the refractive error was corrected. It was all explained to the parents and regular osteopathic treatment was begun. In less than a month practically every lesion was corrected, her vision returned to normal and she also was cured of an annoying backache with which she had been bothered for years. Her nerves were depleted a great deal. She got benefit in ways that she had not dreamed of. This approach to the eye is not considered by physicians in general, even the oculists. I have had about ten special courses in medical colleges and hospitals on the eye, ear, nose and throat, and I have never heard anything mentioned that would indicate any ideas of the logic involved in this case. Surely osteopathy has much to offer in eye troubles that is new and unique. The osteopathic examination of the eye then should begin with the feet, going then to the innominates, lumbar, dorsal, ribs and cervical regions. Oculists are too prone to rely upon crutches (glasses) in the treatment of asthenopia.
It is easy for the osteopath to conceive how lesions of the upper dorsal and cervical regions may occur and disturb the nerve and blood supply to the eye. This is why asthenopia appears so frequently with ordinary use of the eyes, even without abuse or refractive errors.
The Lumbar Region
The lumbar region should be carefully examined, especially for any curvature which might cause a disturbance of the equilibrium above. Compensatory curves or individual lesions would be the result with a consequent interference with the integrity of the nervous reflexes to the eye.
The Dorsal Region
The same may be said of the dorsal region as of the lumbar in regard to curvatures. There is one individual lesion in this region that very frequently exists with eye troubles, i. e., the 2nd dorsal vertebra lateral. Any of the upper four dorsals in lesion may be a causative factor in predisposing to disease of the eye but it has been my observation that the 2nd is involved most often. In severe headaches due to eye strain from refractive error, a good diagnostic symptom is tenderness and contraction at the 2nd dorsal even when there is no subluxation.
The Cervical Region
This region should have particular care in search for individual lesions. It is quite easy to pass over some small cervical lesion that may be causing serious disturbance, especially if the neck happens to be fleshy. I have corrected cervical lesions and stopped twitching of the eyelids (orbicularis palpebrarum) and other muscles about the face.
The first case I ever saw was twenty-two years ago when I was a junior at Kirksville. Dr. F. P. Millard, now of Toronto, was a room mate of mine. He was constantly annoyed by a twitching of an eyelid. I did not find any lesion for it. We went one day to see Dr. Still at his home and told him of our difficulty. He said without examination that the 3rd cervical was in lesion. There was a senior student present whom the “Old Doctor” directed how to use the proper technique. There was a sharp pop, the vertebra evidently went into right relation, the twitching stopped. I understand the patient has had very little trouble since.
Injuries, exposure and strains to the spine may have antedated an innominate lesion and caused weak joints, muscular and ligamentous tension, local inflammations and partial immobilization of joints. All this would have its modifying effects upon the manifestation of secondary lesions from the innominate abnormality. This makes the study of the bony relations very complex and the effect upon the numerous blood vessels, nerves and other soft tissues still more complicated.
The Ciliospinal Center
Following osteopathic examination and giving proper importance to lesions below the fourth dorsal vertebra, we must remember a special significance to be attached to lesions of the upper dorsal in relation to the eye.
Almost any author on nervous diseases or diagnosis will discuss this center. Many of us have it not sufficiently impressed, hence I repeat some known relations. The ciliospinal center consists of a nuclear group of cells in the lateral horn of the last cervical and two upper dorsal segments of the spinal cord. From this nucleus fibers pass to the anterior division of the eighth cervical and first and second dorsal nerves and become the white rami communicantes which are efferent in their function. These fibers pass to the inferior cervical sympathetic ganglion, thence upward with the sympathetic trunk through the middle and superior cervical sympathetic ganglia, along the carotid plexus to the vessels of the face and eye, to the glands of that region, to the unstriped muscular fibers of the levator palpebræ superioris and to the dilator pupillae muscle.
Any strong feeling or emotion (which of course is perceived and interpreted by the brain cortex) will cause a dilatation of the pupil of the eye. The cervical sympathetic being cut, dilatation does not take place. The rami of the cervical, first and second dorsal cut, the phenomenon stops. It is evident the ciliospinal center is under the influence of a center or centers in the brain. Bing says “There is even an idiomotor mydriasis, which may be brought about by a very vivid mental conception of darkness.”
It has been noted that paralyzing lesions of the cervical sympathetic, of the last cervical and two upper dorsal segments of the cord, and of the anterior roots and rami communicantes of the same, will result in myosis.
The efferent rami are also vasomotor, secretory and trophic. It must necessarily follow that congestive and inflammatory conditions, secretory perversion of the lachrymal, Meibomian, Zeissian and perspiratory glands, and disturbance of the normal nutrition of any of the orbital tissues may result from lesions of the lower cervical and upper dorsal vertebræ.
Osteopathically we know that such a lesion may not be sufficient to be paralytic in its effect, but stimulatory. In this case we may note a pupil habitually too wide and more or less photophobia from a superabundance of light. The unstriped muscle fibers in the levator palpebræ superioris may be unduly contracted making an appearance of a slightly bulging eyeball when it is only a wide open eye.
One who has eye strain from a refractive error, overuse of the eyes, or unbalanced muscles will as a rule have tenderness at some spot in the region of the ciliospinal center. A mechanical lesion at that part of the spine may or may not exist in such conditions, but I believe the soreness is there every time. This is one of the diagnostic points in differentiating headache of eye strain from other conditions.
White rami are only in the dorsal region and to the second lumbar and from the second, third and fourth sacral. It has been noted that lesions of the cervical vertebræ do not have as profound an effect upon the eyes as do lesions of the first three dorsal vertebræ. The plausible explanation of that is that the cervical vertebræ have no white rami from their corresponding nerves in the bulbo-spino-sympathetic-ciliary arc as have the upper dorsal.
From all the foregoing statements one can readily contemplate the intricate complexity of our osteopathic problems in relation to the eye. Combine this logic of the lesions outlined and the ramifications of the structures with their normal and perverted functions and combine it with contributing causes, such as infection, exposure, irritants, etc., and amidst the great diversity we reduce much miscellaneous, unclassified material to a degree of simplicity. Many otherwise unexplainable conditions become reasonably clear.
Dr. Louisa Burns under “The Experimental Demonstration of Osteopathic Centers” has this to say:
“Somatic Reflexes”
“In the first series of experiments, the electrodes were placed upon the nasal mucous membrane of animals under anesthesia. The muscles near the third thoracic vertebra were at once strongly contracted....
“The electrodes were then placed upon the conjunctivæ. The muscles near the second vertebra were then contracted. There were also slight and inconstant contractions of the cervical muscles....
“The electrodes were placed upon the eye ball. The muscular contractions were sometimes noted near the second thoracic vertebra, but the reaction was not constant. The cervical muscles were scarcely contracted at all.
“The electrodes were placed upon the outer surface of the eye lids. The facial muscles were contracted very quickly and forcibly, but no contraction of the muscles of the upper dorsal region were noted....
“The superior cervical ganglion was exposed to view, and the electrodes placed upon it. The pupils became greatly dilated, the conjunctivæ became lighter in color, and the mucous membranes of the nose and throat were also lightened....
“The Gasserian ganglion was exposed to view. The ganglion was stimulated directly. The upper thoracic muscles were very strongly contracted, and the blood vessels in the area of the distribution of the fifth nerve were immediately and strongly contracted. Some of the sympathetic fibers are carried by way of the fifth nerve. In order to exclude the effect of the direct stimulation of these fibers, the fifth nerve was cut, and the central end was stimulated by the electrodes. The muscles of the upper thoracic region were contracted, as before. The vessels in the area of distribution of the fifth nerve were contracted after latent period of a minute or so....
“The stimulation of the central end of the cut fifth nerve caused strong muscular contractions in the upper thoracic region, and also constriction of the vessels in the area of distribution of the fifth. Direct stimulation of the superior cervical ganglion produced effects identical with those produced before the mutilation.
“The spinal cord was cut above and below the superior cervical ganglion. This cut was made from behind, and the sympathetic chain was uninjured. The effects noted after both operations were the same, and can be described as one.
“The stimulation of any cranial structure failed to cause reflex contraction of the muscles in the upper dorsal or the cervical region.
“Stimulation of the cranial structures did not produce any vascular changes except those which might be referred to the direct effects of the electricity upon the vessel walls.
“Direct stimulation of the superior cervical ganglion produced the effects noted before mutilation.
“Therefore the cervical portion of the spinal cord is an essential element of the reflex arc by way of which sensory impulses from the cranial structures are able to affect the condition of the upper dorsal muscles, and also in the path by which these impulses are able to affect the size of the blood vessels of the cranial structures themselves....
“Mechanical stimulation of the tissues near the second thoracic spine was followed by a contraction of the blood vessels of the cranial mucous membranes and the conjunctivæ, by a dilatation of the pupils, and an increased secretion of saliva. These effects were practically invariable....
“The superior cervical ganglion was subjected to mechanical stimulation by the manipulation of the tissues over it. In animals, this maneuver was followed by dilatation of the pupils and by a contraction of the cranial vessels, which was soon followed, if the stimulation continued, by a dilatation which was rather persistent.
“After the extirpation of the Gasserian ganglion without the injury of the sympathetic nerves, the mechanical stimulation of the tissues near the second and third thoracic vertebræ caused the same vaso-constriction and pupilo-dilation as was observed in the animal before mutilation.
“After the destruction of the cervical portion of the sympathetic chain, and after the extirpation of the Gasserian ganglion in most animals, the mechanical stimulation of the tissues in the upper dorsal region did not produce any perceptible effects....
“Mechanical stimulation of the tissues near the second and third thoracic spines caused dilatation of the pupils and contraction of the vessels of the cranial mucous membranes.
“Inhibition, or the maintenance of an artificial lesion, caused dilatation of the vessels of the nasal mucous membranes and of the conjunctivæ. The eye ball was also somewhat congested. The pupils were dilated in this case also.”
The Nose and Throat in Eye Trouble
An examination of the eye would not be complete without a careful inspection of the nose and throat. The same nerve and blood supply that go to the eye is tied up so definitely with the nose and throat that when there are lesions of the nose and throat the eye is often affected secondarily. Just recently a case of dacryocystitis came into my office. After I had carefully examined her eye, spine, nose and throat, she informed me that she had been to three eye specialists before and not one of them had ever looked at her nose and throat, not to mention the spine. She had cervical and dorsal lesions, and diseased tonsils. The inferior turbinate on the side of the dacryocystitis was curled out so that it lay against the external wall of the nose almost if not altogether blocking the entrance of the lacrymal duct to the inferior meatus. This was evidently the predisposing cause of her dacryocystitis.
In neuralgia of the eye, blepharitis, obscure pain, conjunctivitis and often deeper troubles you will find a bad condition of the nasopharynx, such as adenoids, vegetations, pus pockets, adhesions in the fossa of Rosenmuller, contraction of the soft palate, disturbed relations of the septum and turbinates, sinus trouble, poor drainage, exostoses and polyps. In eye disease all these things should be discovered if they are present, in order to get best results and in order to make a careful diagnosis.
Examination of the Eye by Special Methods
The first thing after the family history, personal history, inspection of the eye and the osteopathic examination, is to find out how well the patient can see. To test the acuteness of vision certain test letters are used. Snellen’s Test Letters are good. The normal eye can read 3-8 inch letters at twenty feet. The test letters on the cards usually range in size to be read at 10, 15, 20, 30, 40, 50, 70, 100 and 200 feet. The most desirable distance is 20 feet. If at the distance of twenty feet he reads the 3-8 inch letters his acuteness of vision would be marked 20-20 or normal. Always use the distance between patient and chart as the numerator of the fraction and the number above the letters which he reads as the denominator. If he is twenty feet away, the numerator remains twenty and the denominator changes according to the line of letters seen on the test cards thus: 20-15, 20-30, 20-70, or 20-200 may express the vision. If the patient could not see the 200 feet letters at 20 feet he must be brought nearer, say 10 feet, for him to see the large letters; his vision would be 10-200. These fractions representing the acuteness of vision may be expressed in meters. Some charts have letters numbered that way.
If the vision is good enough for small objects to be clear, the near point should be taken. This would show the amount of accommodation of the eye. This is expressed in diopters.
A diopter is the unit of measurement of the refractive power of lenses. Lenses are numbered by their refractive power in diopters. A lens that has a curvature that will refract parallel rays of light and bring them to a focus at one meter distance is said to be a one diopter lens. This unit of measurement for the refractive power of lenses was proposed by Nagel in 1866. It soon became quite generally used.
The focal distance of a lens decreases as the strength of a lens increases. One diopter lens (written 1 D) has a focus of one meter (1 M) or 100 cm distance. A 2 D lens has a focal distance of ½ M or 50 cm. A 4 D lens has 25 cm focal distance and a ½ D lens has 100 cm ÷ ½ = 200 cm distance or 2 M. Trial cases have in them lenses varying in strength from .12 D or .25 D to 20 D of the spheric form. We will not discuss the trial case here.
Accommodation in the Eye
Accommodation in the eye is the ability of the eye to vary its focal point. When the normal eye (emmetropic) is at rest its focal point is at infinity so far as parallel rays are concerned. This is called the far-point or the “punctum remotum” (P. R.).
When the eye looks at letters twenty feet away it scarcely accommodates at all to get a focus, or so little that it may be disregarded in ordinary practice. Now if one brings fine print close to the eye he will find a point so close that it becomes indistinct. This point is the near-point of focus or the “punctum proximum” (P. P.). The range of accommodation is the difference between the refractive power of the eye when it is at rest and when the accommodation is exerted to the utmost, the difference between the P. R. and the P. P.
If one must accommodate one diopter to get a focus at one meter or forty inches distance, at thirteen inches or reading distance one must accommodate at least 3 D in order to see the letters clearly. If 3 D were the total of his accommodation he could not read at that distance but a few minutes; because the accommodation could not be held at its maximum for long at a time. Eye strain with its train of symptoms would result. Hence it is quite important to find the near-point or punctum proximum in order to judge in regard to eye strain in an emmetropic eye. If there is a refractive error, allowance for it must be made accordingly.
As a person gets older the accommodation in the eye becomes less and less until at 45 years of age he can only use 4 to 5 D of accommodation. This is so close to the amount required for reading that he has some eye strain. He begins to hold his paper farther away from him so he requires less accommodation. This condition we call “old sight” or presbyopia. An emmetropic eye at forty-five to fifty years of age requires a plus glass to make up for some accommodation in reading.
Frequently there are latent disturbances of equilibrium of the extrinsic muscles of the eye. This is heterophoria. If it is a latent convergence it is esophoria; if a latent divergence it is exophoria. The latter is more frequent. Hyper- and hypophoria are used for upward or downward tendencies. Normal muscular balance is orthophoria.
Cause the patient to fix on an object about thirteen inches away with both eyes; push a sheet of paper in front of one eye and watch behind the paper, the eye thus covered. If heterophoria exists the eye will move slightly from its point of fixation since it no longer sees the object. In orthophoria it will remain fixed as long as the other eye sees the object; the innervation to the different muscles is properly distributed.
A Maddox rod found in any complete trial case may be placed before one eye. Have the patient fix on a candle flame, say twenty feet away. The flame appears drawn out into a luminous line. This line can not be fused with the candle flame as the other eye sees it if there is heterophoria. The amount and kind of disturbance is somewhat indicated by the distance and direction of the luminous line and the flame. The exact amount can be measured by the use of a prism that will cause them to fuse.
Next the patient should be taken to the dark room and a careful inspection of the anterior segment of the eye should be made with oblique illumination. First use the unaided eye, then use a lens that magnifies. The 20 D plus lens from your trial case will suffice for the magnification. Note the transparency or lack of it in the cornea and crystalline lens; the depth of the anterior chamber and the appearance of the pupil and iris. Now we are ready for the ophthalmoscopic examination.
The Ophthalmoscope.—This is an instrument that commands great respect. Any one who is interested in eye troubles must have and use the ophthalmoscope if he expects to be efficient in diagnosis, upon which, of course, intelligent treatment must forever depend. One must try and try again in order to become proficient in the use of the ophthalmoscope.
A Schematic Eye is of great assistance to a beginner who does not have clinics or patients on whom to practice. Such an eye with full directions can be obtained at almost any optical goods store. It will make the study of ophthalmoscopy easy and interesting. The pupil can be regulated to any size and the eye can be made short (hyperopic), long (myopic) or normal (emmetropic) for study.
The efficient use of the ophthalmoscope makes the diagnosis of internal diseases of the eye as easy as the diagnosis of external diseases of the eye. Only some rare conditions will puzzle, and that is true of any part of the anatomy.
The ophthalmoscope is a simple instrument; its chief function is to illuminate the interior of the eye. The value of ophthalmoscopic findings depends on their correct interpretation by the examiner.
The ophthalmoscope has a mirror to reflect the light into the eye. It has two discs on which are mounted convex (plus) and concave (minus) lenses. The larger disc has seven plus and eight minus lenses. To these may be added the lenses in the smaller disc making many combinations.
A drop of a 2% solution of cocaine or homatropine may be used as a mydriatic where one can not otherwise see clearly the fundus. If no mydriatic is used a somewhat weak illumination should be employed in order not to arouse the accommodation to much activity and make the pupil small. If there is any opacity in the media a strong illumination should be used. The room should be dark; the darker the better.
There are two methods of using the ophthalmoscope. The indirect and the direct methods. One is more useful at one time and the other at another time. By the indirect method we view the whole field of the fundus more readily but less in detail. With the ophthalmoscope before his eye the examiner’s face is twelve to fifteen inches from that of the patient. When the “red reflex” of the eye is seen a plus 13 or 16 D lens is interposed near the patient’s eye. This magnifies the field. The image is inverted. As a rule it is best seen with a +4 D lens in the aperture of the ophthalmoscope.
This method is especially more satisfactory in high degrees of myopia and astigmatism. The optic disc is the objective point. One may see a retinal vessel first; this should be followed to its emergence from the disc. From this point view all parts of the fundus by having the patient look in different directions. This is better by the indirect method than for the examiner to vary his position.
The direct method of ophthalmoscopy is better for detail work and in all cases except high degrees of myopia and astigmatism. It is also better in determining errors of refraction. The patient looks straight across the room. For a beginner it may be essential to dilate the pupil, hence the schematic eye as suggested.
If the examiner has a refractive error, he should wear his own glasses or correct by throwing in front of his eye proper lenses in the ophthalmoscope. Face the patient and sit on the side of the eye to be examined. Use left eye to examine the patient’s left eye and right eye for the patient’s right. Examiner and patient keep both eyes open. The examiner may not be able to suppress the image of his other eye and may have to close it part of the time. Catch the “red reflex” some 15 to 18 inches away and move close to the patient’s eye. The “red reflex” color varies with the error of refraction, the transparency of the media, the degree of pigmentation and the size of the pupil. A blood clot will make it redder, some exudates will make it gray or yellow.
The examiner may approach as close as half an inch from the eye to be examined. Find the optic disc and examine all points of the fundus from it. Rotate in glasses to correct the patient’s refractive error if he has any. The strongest plus glass with which the fine retinal vessels can be clearly seen will represent the hyperopia of the eye. This is true only if the examiner’s accommodation is at rest. The weakest minus glass with which the fine retinal vessels can be clearly seen represents the myopia.
A Normal Fundus.—The color of the fundus is due to the blood vessels of the retina and choroid and the connective tissue of the choroid and sclera. Variation is due to the pigment. In the albino it is light pink. In the negro it is dark reddish. There are all gradations between the two.
The optic disc is the end of the optic nerve as it comes into the eye; it is circular in shape, pink in color, and sharply defined. It is about 1-16th of an inch in diameter; about 15° to the nasal side of the pole of the eye and slightly above the horizontal. There may be a dark choroidal ring around the disc or part way around. There may also be a white ring caused by the sclera. As a rule there is a depression in the center of the disc out of which the retinal vessels emerge and spread out over the fundus.
The fovea centralis or point of clearest vision is located two and a half disc diameters to the temporal side of the disc. Around this is a circular area of light yellow, the macula lutea.
The subject of ophthalmoscopy has been touched upon somewhat in detail because of its great importance to the general practitioner. Every osteopathic physician should know the ophthalmoscope well enough to recognize the ordinary lesions inside the eye. When we take up pathological conditions of the eye we will have occasion frequently to refer to the ophthalmoscopic appearance. Without the use of this instrument all of our clinical field research on internal diseases of the eye is valueless. Many have told me they have cured cataract with osteopathic treatment, some say they have cured specific neuroretinitis with no sequelæ, others testify to opacities and blindness from various causes. Invariably we ask if they used the ophthalmoscope in their diagnosis and with it watched the progress of the case. Almost invariably the answer is “no, it looked like it,” “the symptoms indicated it,” or “Dr. so and so, an oculist diagnosed it as such.” Fellow Osteopaths! we can not base our claims on this kind of data. With a little study and practice the ophthalmoscope can be mastered. Not till then can we get reliable statistics on internal diseases of the eye in our case reports. Osteopathy has much to reveal to us in this field and for the sake of the science and our patients we appeal to every one to do the work here set forth.
Diseases of the Eye
Osteopathic Manipulation for Eye Diseases
A general correction of lesions should be made in order to give perfect alignment and equilibrium. Lesions that affect the nerve and blood supply will be found from the fourth thoracic to the occiput; more often at the occiput, atlas and axis in the cervical region and the second and third thoracic in the dorsal region including the ribs.
Correction of these lesions must have specific attention in every case of eye disease that shows any tendency to chronicity or in repeated eye disease and exacerbations.
A thorough upper spinal treatment to insure good mobility of all joints and establish freedom of fluids and forces is recommended.
The nose, throat and sinuses should be examined for pathology. If the tonsils and pharynx are not normal the cotted index finger should be introduced into the mouth until the anterior pillar of the fauces is reached. A mouth gag may or may not be used. Massage the tonsil through the anterior pillar then move to the top and press down on the tonsil with a pumping motion. Repeat this from below the tonsil and posteriorly. Slip the finger under the soft palate and stretch it thoroughly. Clean out any adhesions and vegetations in the vault of the nasopharynx and fossa of Rosenmuller. Stretch the pillars of the fauces by pressing down on each side at the root of the tongue.
If the sinuses are diseased they should be drained. If the nose is diseased and has abundance of secretion, first use irrigation for cleanliness.
Manipulation in the nose will be of great benefit in some eye diseases as pathology there frequently has an important bearing on diseases of the eye. The nose is often too narrow and contracted. The first inch of the nose is muscular and cartilaginous; it is of even more importance to dilate the nose in contractured conditions than it is the sphincters at the lower end of the rectum. The great benefit derived from rectal dilatation has been recognized for years.
In dilating the contracted nose a wide blade nasal speculum may be used. The cotted and oiled little finger may be used where it is properly adapted in size. The dilating can be done with practically no pain and no damage to membranes or other tissues. It should not be extended beyond the cartilaginous and muscular part. Manipulation of the turbinates and tissue further back may be done if needed, by the use of instruments. The Edwards turbinate adjuster instrument (Aloe Co., St. Louis) or the Ruddy Nasal Third Finger (Sharp and Smith, Chicago) are the best instruments so far devised for this operation.
A thorough stretching of the eyelids, manipulation of the eye ball and the points of the fifth nerve are indicated in many diseases.
The lids may be stretched by pulling them from side to side. The cotted forefinger well oiled (sterile vaseline) may be slipped into the conjunctival sac back of either lid and with the thumb on the outside the lid may be massaged or stretched in any direction. The points of the fifth nerve may readily be influenced at their respective exits about the orbit. The eye ball and deeper contents of the orbit can be profoundly treated by pressing the finger into the orbit above, below and at the sides of the bulb and pushing it in all directions as far as possible. The Ruddy eye finger instrument was devised for this deep manipulation of the orbital and bulbar structures. It is of high value. One finger may be laid on the closed eye and with a tapping motion with the other hand a vibration or oscillation of the orbital structures may be had. This is a useful treatment.
The wise selection and skillful use of these various methods of treatment for the eye will solve most of our difficulties.
This short survey of osteopathic methods will aid us in the more specific discussions to follow.
Neuralgia
A considerable number of people seem to be subject to attacks of pain in one or both eyes. These attacks of pain come at varying intervals; in some cases several times a day, in others as far apart as one or two weeks. The pain will suddenly start almost without warning and with very little provocation, and last from one to twenty-four hours. It is very severe and the patient frequently thinks something terrible is wrong. Something terrible is wrong so far as his comfort is concerned. But in these cases to which I am referring there is no organic trouble with the eye. The patient does not need glasses. There is no sign of inflammation. Vision is not disturbed. Local examination of the eye with the ophthalmoscope reveals that the fundus of the eye is normal. There is no symptom connected with the eye except pain, occasionally accompanied by a slight redness. I have had several cases in my own practice and my attention has been directed to cases of other physicians.
These cases differ from tic douloureux in that there is no muscular spasm. In fact, motor nerves do not seem to be involved. The involvement seems to be largely in the fifth cranial nerve, usually the supraorbital, or other smaller branches of the ophthalmic division of the fifth cranial. Sometimes we note slight dilatation of the pupil with more or less congestion. This would indicate an involvement of the sympathetic branch to the eye.
The lesions discovered in these cases have been a subluxation of the occiput upon the atlas or an upper cervical lesion and frequently some involvement at the second dorsal. There has been noted also trouble in the nasopharynx such as contractures of the muscles of the soft palate and adhesions in the fossa of Rosenmuller.
Misplacements of the uterus have also been found in some cases.
Treatment
Nearly all these cases are curable with from one week to six weeks treatment. Of course the treatment must be intelligently directed after a correct diagnosis as to the cause. The cause can usually be removed. One case to which my attention has been directed was that of a woman about forty years of age who had very severe pains. With all the local treatment of the eye and otherwise she got practically no results until she had replacement of the uterus, which brought immediate relief. Other cases have no trouble on that kind but have lesions of the cervical region and on correction of these lesions the neuralgia disappears. Other cases have had the nasopharynx cleaned out by the finger operation and the stretching of the soft palate which relieved the neuralgia immediately or in a few days. Numbers of cases have been to medical physicians and had various eye remedies administered locally with no permanent benefit. Of course the treatment was administered at the wrong place.
The ramifications of the sympathetic and fifth cranial nerves are so complex and far-reaching that we must keep in mind that one or more of many causes for the trouble may exist and be quite remote from the seat of the pain.
Diseases of the Eyelids
Occasional factors are bee stings or insect bites, which completely occlude the palpebral fissure. We may have some palpebral edema from lid abscesses, chalazion, hordeolum, dacryocystitis, panophthalmia and so forth. In hemorrhagia subdermalis there is so much spongy tissue beneath the skin about the eye that the blood extends easily and far. The red tint will soon change to a reddish blue and then become dark, what is known as a black eye (ecchymosis). This frequently results from a blow. The skin is sharply attached around the orbital margin by tense connective tissue so the area of the hemorrhage is limited to the region of the orbit. There may be spontaneous rupture of some of the vessels by hard sneezing or coughing, especially in young children. In older people it may indicate a fragile condition of the vessels, arteriosclerosis or some trouble with the kidneys. The diagnosis of the eye condition is not difficult but the cause of the hemorrhage in that region might be investigated further. Local treatment is of some value in these conditions. They may be soothed by cold compresses. In bee stings and insect bites use an alkaline compress. Manipulation about the eye and osteopathic treatment of the neck with a view to directing a better circulation to that region will aid much.
Herpes Zoster Ophthalmia
This affection of the supraorbital branch of the fifth cranial nerve may extend to the eyelids. It may not go beyond the stage of blistering and redness with some edema. However, it is possible for it to become gangrenous and even extend to the conjunctiva and cornea. I had one case of herpes zoster gangrenosa of this region. There were several gangrenous spots as large as a dime on the forehead and extending down in the region of the eyelid. The process extended to some extent on the cornea and in healing left a condition of irregular astigmatism.
Treatment.—The prognosis in herpes zoster is always favorable under osteopathic treatment. Lesions of the cervical region will almost invariably be found interfering with the sympathetic connections of the fifth cranial nerve causing the trophic disturbance to the region. Osteopathic treatment applied to these conditions will always hasten normalization. The affected part might be kept covered with some soothing lotion to keep the skin soft.
Hordeolum
This is commonly known as a sty. It is due to suppuration of the glands of Zeiss. It is a harmless affection but causes pain and inconvenience.
Diagnosis.—Swelling and pain with a small inflammed nodule in the palpebral margin is quite diagnostic.
Treatment.—The circulation is obstructed in this region. The effort should be made to open the circulation before pus has formed. This can frequently be done and the hordeolum aborted by carefully picking up the eyelid and rolling the nodule between the fingers. This will cause some pain but if it is kept up for a moment or two about every hour through the day with an occasional thorough treatment of the neck the sty will usually be aborted. If pus forms it should be opened as soon as it points and then the squeezing and rolling process may be employed again, which will aid rapidly in the freeing of the circulation.
Chalazion
This is a Meibomian cyst in the eyelid. It shows as a circumscribed swelling on the inner side of the lid. It frequently becomes large enough to produce some deformity of the lid. A chalazion is movable on the tarsal cartilage. It is a chronic condition and the cyst may become as large as a bean. There may be more than one in the same lid.
Treatment.—When a chalazion is small and not of long standing it can frequently be cured by osteopathic treatment. Introduce the finger into the conjunctival sac under the lid, and with the thumb externally, grasp the chalazion between the finger and thumb; roll it thoroughly. Squeeze and massage it two or three times a week for awhile. This, combined with a thorough treatment of the neck, will result in a cure. If at the end of six weeks the condition has not disappeared surgery should be resorted to.
Blepharitis
This is an inflammation of the eyelid. It is either acute or chronic according to the cause. Acute blepharitis may be due to heat or injury. Chronic blepharitis affects the glands of the lid causing a perversion of the secretions. There is usually the formation of crusts and scales. This condition is known as blepharitis sicca. In some cases infection will form little pustules at the roots of the cilia. There is soreness and aching. There may be photophobia. The nasal region may be involved. Osseous lesions of the cervical region are usually present. Refractive errors frequently exist in these cases. Occupation or environment may expose to dust or wind sufficient to keep up the irritation.
Treatment.—Change environment. See that there is thorough cleanliness of the lid. Rub or pick away all scales. Use a bland ointment. Correct any cervical or upper dorsal lesions.
Ptosis
This is congenital or acquired. In congenital ptosis operation seems to be the only treatment. Acquired ptosis is amenable to treatment frequently. The cause is some lesion interfering with the passage of proper nerve force to the levator muscle of the lid. The lesion may be at the origin of the third nerve, at the cortical nucleus in the sigmoid gyrus or in the trunk of the third nerve, or a lesion of the muscle itself. Tumor, trauma, syphilis, sclerosis, hemorrhage, gout or rheumatism, or anything that will produce a peripheral neuritis are causative factors. Lesions of the cervical and upper dorsal by reflecting back upon the nerve centers may produce a ptosis.
Treatment.—Remedial measures according to indications. Cases due to osteopathic lesions as indicated will usually yield readily to treatment. Where there are other factors treatment must be varied accordingly.
Trichiasis
This is a condition in which part or all of the eye lashes turn inward and touch the eye ball, due to cicatricial contractions in the conjunctiva and tarsus. Many of the cilia are so small in these conditions that it is very difficult to see them. A loupe or a magnifying glass must be used in order to discover them.
Dystrichiasis is a condition where the cilia come in irregularly growing in all directions, some of them turning in toward the eye ball and causing irritation.
Treatment.—An epilatory should be used to extract all of the wild hairs. Care should be taken to get out the finest ones as they will frequently cause irritation if not removed.
Entropion and Ectropion
Entropion is a turning in of the eyelid and ectropion is a turning out. These conditions may be spasmodic and temporary. Entropion is more often due to cicatricial contraction in old blepharitis or trachoma conditions. In some cases the condition may be corrected by the use of strips of adhesive plaster. In cicatricial conditions operation is the rule. Spasmodic ectropion may be corrected sometimes by curing the conjunctivitis. Bandaging may be resorted to. In paralytic ectropion osteopathic treatment may serve to produce a complete cure. Operative procedure should be a last resort.
Diseases of the Lachrymal Apparatus
Dacryocystitis
Dacryocystitis is an inflammation of the lacrymal sac. It is due to some lesion in the nose, malposition of the inferior turbinate or a poor blood and nerve supply to the lacrymal region as determined by cervical lesions. The sac becomes infected and we have a dacryocystoblennorrhea. Pus and tears are regurgitated into the eye through the puncta. There is irritation and the conjunctiva may become infected at any time, also the cornea. It is a dangerous and annoying affection.
Treatment.—Osteopathic measures have something to offer along this line. The medical idea seems to be completely surgical in recent years. The first and only thing to be done surgically is to obliterate the sac or dissect it out and curette the nasal duct, completely destroying the apparatus. Lancing does not affect a cure. By treating for a good nerve and blood supply to that region, the irrigation of the nose and a thorough squeezing of the sac each time with a view to forcing the solution in the sac down through the nasal duct into the nose, a cure may be effected in many cases. If these cases can be gotten before infection has taken place, in the state of epiphora or the backing up of the tears into the eye, thorough treatment along the lines just indicated will in nearly all cases result in a cure.
Boric acid solution should be used to wash out the sac when pus is present. The attempt should be made to force it into the nose. Probing properly done is of value in many cases. These cases should be followed up with great care.
Treat the neck thoroughly and spring the inferior maxilla.
Diseases of the Conjunctiva
Conjunctivitis
The conjunctiva is a mucous membrane that coats the posterior surface of the eyelids and the anterior surface of the eyeball. It forms a sac, which is slit open in front in the line of the palpebral fissure.
The conjunctiva consists of three parts (1) the conjunctiva tarsi, the part on the lids; (2) the conjunctiva bulbi, the part on the eyeball, and (3) the conjunctiva fornicis, the part connecting the first and second; it is the retrotarsal fold or the region of transition, often called the fornix. The first part can be seen by everting the lids. It is adherent to the tarsus. It is covered with a laminated cylindrical epithelium. The membrane contains an abundance of lymphocytes similar to adenoid tissue. This increases with every inflammation of the conjunctiva. This is why chronic conjunctivitis often results in thickened lids.
The blood supply of the conjunctiva of the lids is from the muscular branches of the ophthalmic artery. The nerve supply is from the ophthalmic division of the 5th cranial and the sympathetic.
The bulbar conjunctiva continues over the cornea. It is covered with layers of pavement epithelium. Its blood supply comes from the posterior conjunctival vessels about the retrotarsal fold, and the anterior ciliary arteries which accompany the tendons of recti muscles; these two systems anastomose in the conjunctiva. Conjunctival injection or congestion shows a superficial net work of larger or smaller vessels that move with the conjunctiva. The color is scarlet or brick red. Ciliary injection occurs as a rose-red or pale violet zone around the cornea, spoken of as peri-or circumcorneal injection. It does not move with the conjunctiva and occurs more with diseases of the cornea, iris and ciliary body.
In the etiology of conjunctivitis a great variety of germs are considered by different writers. Collins and Mayo give a report of “germs found in normal conjunctiva.”
Bacillus Xerosis in 94% of normal conjunctivæ; Staphylococcus Albus in 79%; Pneumococcus in 9%; Diplobacillus in 6%; Staphylococcus Aureus in 6%; Streptococcus in 5%.
If this be true, and I do not doubt their statement, we are practically compelled to say that these germs at least are only secondary in the etiology of conjunctivitis. Just at this point osteopathy comes with its flood of light and makes it easily explainable why some conjunctivæ become inflamed while others do not, when all have germs present. The lesion disturbing the integrity of blood supply and nerve force to the eye is the primary cause while the presence of germs may be the aggravating cause. The lesion prepares the soil in which the germs thrive sufficiently to become an irritant. There are all gradations of this soil preparation. The more fertile the field (i. e. the more profound the effect of the lesion) the more virulent germ life may become; the resistance is proportionately less.
Conjunctivitis is classified for convenience in study, diagnosis and treatment as follows:
(1) Catarrhal, (a) acute, (b) chronic, (c) follicular; (2) gonorrhoeal; (3) ophthalmia neonatorum; (4) trachoma; (5) diphtheritic; (6) eczematosa (phlyctenulosa); (7) vernalis; (8) tubercular; (9) traumatic. This is the clinical classification after Fuch.
Treatment of Conjunctivitis
In order to give the best care in these cases it is quite essential that both the primary and secondary causes be given attention. Some good germicide or antiseptic is to be used with intelligence. This is in harmony with the great principles of antisepsis and cleanliness taught by osteopathy from its inception. The use of the microscope in the bacteriology of conjunctivitis aids in more definite diagnosis and the selection of a proper germicide. For the Koch-Weeks bacillus, the pneumococcus and the influenza bacillus silver nitrate 1% or a 25% solution of argyrol is used; for the diplo bacillus (Morax-Axenfeld) zinc sulphate 1 gr. to the ounce is almost a specific.
A good way to prepare the zinc prescription would be:
Boracic acid and water oz. 1.
Zinc sulphate gr. 1.
The boric acid and water of course being a saturated solution. Apply one drop to each eye about four times a day. If one can not have the use of the microscope to make specific the diagnosis, the zinc solution may be alternated with the argyrol as the germicide. Ice cold applications are good in many of these cases.
Catarrhal Conjunctivitis
Acute.—mostly affects the conjunctiva of the lids in the light form. If severe it invades the bulbar conjunctiva. There is redness and swelling and increased secretion which dries at night upon the edges of the lids and glues them together. The eyes are better in the morning and worse toward evening. Corneal ulcers and iritis may arise as complications. Chronic inflammation may result.
Etiology.—Textbooks on the eye give bacteria as the chief cause; some scarcely mention anything else. After discussing how the bacteria get there and multiply, they usually bring in some statement to indicate that in many cases no bacteria can be found in the secretions from the conjunctiva. These latter are unaccounted for in the etiology.
Catarrhal conjunctivitis is non-specific in its origin.
The great science of osteopathy will fill in the missing links to works otherwise very exhaustive on the eye.
If the cause is due only to a passing irritant as dust, smoke, pollen or wind the disturbance may vary from hyperemia only, to a severe attack of conjunctivitis. Fuch says the majority of cases are produced by bacteria, but THAT IN NOT A FEW CASES OF CONJUNCTIVAL CATARRH THE EXAMINATION OF THE SECRETIONS FOR BACTERIA PROVES NEGATIVE. He also says that the usual course of the disease is from eight to fourteen days, but NOT INFREQUENTLY THERE REMAINS A CONDITION OF CHRONIC CATARRH PROTRACTED OVER A LONG TIME; THAT NOT INFREQUENTLY THE NORMAL CONJUNCTIVAL SAC CONTAINS PATHOGENIC GERMS.
Some authors divide the etiology into (1) specific, (2) non-specific. The first they account for by irritants due to dust, heat, smoke, metal, pollen, cold, wind, glare of light, eye strain from overwork of the eyes, ametropia and chronic alcoholism. The second they account for by germ life, most often the Morax-Axenfeld diplobacillus or the Koch-Weeks bacillus, the latter germ being found in the so-called “pink-eye.” It is contagious. This is one condition for which the zinc sulphate (½% to 2% solution) is almost a specific.
No doubt the irritants and the bacteria mentioned, with others, do cause much of our catarrhal conjunctivitis and that one who fails to consider properly the local conditions in practice will be sadly lacking in best results.
On the other hand many cases, treated for local conditions only by very competent men who used the best antiseptics and germicides, have very indifferent results. The acute condition would continue and gradually become chronic. From observation, study and experience there are causes aside from local irritants, ametropia, bacteria, syphilis, rheumatism or measles. There is some disturbance to the integrity of the spinociliary sympathetic arc. In many cases of eye disease note lesion and tenderness at the upper dorsal, the removal of which will cause improvement of the eyes. Many cases of eye strain can be relieved by correction of the first, second or third dorsal, and the use of glasses made unnecessary.
Irritation of the eye will cause more or less tension of the muscles at the second and third dorsal, and stimulation of the tissues near the second and third dorsal spines will cause dilatation of the pupils and contraction of vessels of the cranial mucous membranes; which means vasomotor, secretory and trophic disturbances.
It follows then that an osteopathic lesion at the second or third dorsal will cause or tend to cause disease of the eye. There may be all gradations in the effect produced, the lighter being mere tendency, while again it may be enough to set up profound vasomotor, secretory and trophic changes in and about the eye. The first effect of the lesion may be stimulatory, and later, inhibitory. The normal resistance of the eye would be lowered and naturally, local irritants, bacteria and ametropia would have a more profound effect. This will explain how one can develop conjunctivitis in the absence of a local irritant with no bacteria present, and no eye strain.
All of these causes, or any number of them, may be acting together, and each more virulent because of the influence of the other.
Lesions of the occipito-atlantal joint or any of the cervical articulations may cause eye disturbance. There are no efferent ramicommunicantes in that region and the course of the physical disturbance must be greater in proportion to the eye trouble produced, than at the upper dorsal. It is important however to make a close examination of the entire cervical region in eye trouble.
What has been said on the osteopathic causes of acute catarrhal conjunctivitis applies with equal force to chronic and follicular concatarrhal conjunctivitis.
What has been said on the osteopathic causes of acute catarrhal conjunctivitis applies with even greater force to the chronic form. The great variety of local irritants may account for acute conjunctivitis, and does in most instances; but in chronic conjunctivitis local irritants are more often secondary or incidental while the osteopathic lesion with its effect upon the bulbo-spino-sympathetic ciliary arc is the fundamental cause. Of course some continuous local irritant, e. g., an uncorrected refractive error, excessive light, heat, dust or germ life in the environment may cause a chronic conjunctivitis. Other causes may be retracted lids (lagophthalmus) leaving the eyeballs too prominently exposed; turning in of the cilia (entropion, trichiasis or dystrichiasis) which impinge upon and irritate the bulbar conjunctiva. Chronic blepharitis may spread to the palpebral conjunctiva and then the bulbar. Foreign bodies in the eye, or infarction of Meibomian glands may be causes. The diplobacillus (Morax-Axenfeld) is the most common germ in chronic catarrhal conjunctivitis.
Symptoms and Course.—In mild cases the redness is only moderate. The conjunctiva is smooth and not swollen. Old cases have hypertrophy with thickening. There was a small girl who came into the office recently who had the conjunctiva of the lids decidedly swollen with some hypertrophy. Her eyes were glued shut with pus every morning. Pus pockets were forming along the follicles of the cilia and on the direct edge of the lid. Her troubles started a year ago and got gradually worse. A few osteopathic treatments were given during three months (she was irregular in coming) and argyrol, 20%, used locally. All pus and debris were cleared off the lids and conjunctiva each time. The swelling all left and the thickening became inconsiderable; the eyes looked almost clear. On pressure there was tenderness at the right side of the second dorsal. No mechanical lesion was apparent there but in treatment that region was thoroughly loosened.
The subjective symptoms are usually worse at night; pain, heaviness of the lids; feeling of a foreign body in the eye; burning; itching and dryness in many cases.
This condition is one of the most frequent of eye diseases in adults; may be senile catarrh in advanced age. It is frequently complicated with blepharitis, ectropion, epiphora and ulcerations of the cornea.
Treatment.—The osteopathic treatment depends on the findings in the osteopathic examination. No case of chronic catarrhal conjunctivitis should be treated without a thorough examination of the whole spinal, rib and innominate mechanism. Careful and detailed adjustment should be made of any lesions that might disturb the ciliary arc, the other nerve connections, the blood supply or the body equilibrium.
This does not mean that local treatment of the eye should be neglected in any way. Any measure that will aid in getting rid of local pathology as quickly as possible should be ours. Where there is abundant secretion, silver nitrate 1% to 2% solution put on the conjunctiva with a brush when the lids are turned, or argyrol 20% to 25% dropped into the eye are among the best antiseptics for local use. If the diplobacillus is present zinc sulphate ½% solution is indicated.
The nose, nasopharynx and pharynx should never be overlooked in this disease.
Follicular Conjunctivitis
Follicular conjunctivitis is of catarrhal origin. It is characterized by the presence of follicles. There may be only a few or a great many. If numerous they are often in rows on the palpebral conjunctiva. Microscopically they show as circumscribed masses of adenoid tissue. In this they resemble the granules of trachoma. Sometimes cases persist for years with little or no inflammatory symptoms. On account of the follicles this disease is frequently confused with trachoma.
We have heard numbers of well meaning conscientious osteopathic physicians testify to curing cases of trachoma with a short course of osteopathic treatment with no pathology remaining. We are absolute believers in the effectiveness of osteopathic treatment and want to give it full credit for doing all it will; but here we want to enter a plea to the profession that we need more discrimination and definiteness in our diagnosis. Technique is being emphasized and we say Amen! It is proper for us to be thoroughly competent in technique but diagnosis should be made just as emphatic because scientific technique depends upon diagnosis for each individual case.
Differentiation of follicular conjunctivitis from trachoma.
Follicular conjunctivitis occurs (1) chiefly in the young; (2) the follicles are smaller, more sharply limited, project more above the conjunctiva, are often in rows, and oval in shape; (3) the disease clears up with no bad after effects often without any treatment and the tendency is to ultimately get well; (4) it never leads to shrinking of the conjunctiva, to pannus or other destructive sequelæ; (5) it can arise without contagion and is not considered contagious although, like trachoma, it does attack large numbers of people who are confined in a small place.
Trachoma.—(1) It seldom occurs in children; (2) the follicles are larger, do not have sharp outlines, are less prominent under the conjunctiva, are round in shape and never in rows; (3) tends to lead to more or less pathology and seldom recovers spontaneously; (4) scar tissue becomes a product of the inflammation in the conjunctiva and leads to shrinking of the conjunctiva, causing in turn entropion and trichiasis. Pannus is the sure result of unarrested cases as there is a tendency to infection of the cornea from the infected conjunctiva moving over it and remaining in contact; (5) trachoma has been proved to be contagious. Trachoma bodies which are considered the infective agent have been isolated.
The use of atropine in some instances will cause a follicular catarrh which clears up on stopping the use of the poison.
Parinauds “Infectious conjunctivitis” has granulations but almost always occurs in only one eye and is accompanied with constitutional symptoms.
Treatment of Follicular Conjunctivitis.—The treatment should be directed against the inflammation. The trophicity of the nerve terminals to the conjunctiva may be altered by osteopathic lesions.
Suggestions under chronic catarrhal conjunctivitis apply here. If there is no inflammation the follicles tend to disappear, leaving no trace of pathology, hence a few osteopathic treatments of the lids and the cervical region will hasten normalization.
Gonorrheal Conjunctivitis
This disease is sometimes called purulent ophthalmia or acute blennorrhea, It is caused from an infection of the conjunctival sac with the gonococcus of Neisser. Contact with soiled fingers or linen may transfer the germ.
Symptoms.—Within 12-48 hours after inoculation the first symptoms of redness and irritation occur. This is soon followed by much swelling and tension of the lids and chemosis of the conjunctiva. There is much pain and a copious discharge of pus coming from beneath the lids. At first the pus is yellow or yellowish green.
Later the symptoms begin to subside; there is less tenseness and heat; the lids can be more readily everted and the discharge ceases after 6 or 8 weeks. The puckered conjunctiva becomes rough and granular.
In these cases the prognosis is always grave; more so than in ophthalmia neonatorum. The eye is almost always marred in some way. One of the great dangers is involvement and destruction of the cornea. If the cornea becomes hazy soon after symptoms begin it is not a good omen. Ulcers will likely form and then there is a tendency to puncture the cornea. In mild cases the cornea may escape without injury. In severe cases it is likely to ulcerate. If it perforates, the anterior chamber is emptied and the iris prolapses into the perforation; adhesions take place and there is healing with reformation partially of the anterior chamber. An adherent leucoma is the result with practical loss of vision. There may be a bulging of the cornea known as anterior staphyloma. The iris and ciliary body may become involved, causing iritis and cyclitis, or the whole inner structures may be affected making a panophthalmitis with atrophy of the eyeball.
The cornea is affected by the infective material direct or the nutrient vessels to the cornea at the limbus may be obstructed by the extreme swelling and pressure.
Complications of arthritis, rhinitis, septicemia and endocarditis may arise. If there is none of these, at least there is a general debilitated condition which needs attention.
Treatment.—The treatment should be local and constitutional, The diagnosis should be made quickly from the history, symptoms microscopically, and local cleansing begun at once and followed diligently. Excessive discharge should be wiped away with cotton. The conjunctival sac should be thoroughly irrigated every hour or oftener if necessary to keep it clean. This is to be done day and night. A saturated solution of boric acid may be used, or corrosive sublimate one grain to the pint, or permanganate of potassium solution 1-5000. The irrigation should be followed by the free use of argyrol 25%. This procedure will keep the eye clean and be the means often of saving the cornea from destruction and the eye from blindness.
If there should be ulceration of the cornea a drop of atropine ½% should be used in the eye often enough to keep the pupil dilated and the ciliary body at rest.
Osteopathic physicians no less than other physicians should not neglect this local, careful, persistent, antiseptic cleansing of the eye in such cases. The osteopathist can do more. He is not limited to antisepsis even in this kind of work, however important it might be. The unaffected eye should be carefully protected. Buller’s shield should be used.
The osteopath should give thorough treatments to the neck and the fifth nerve.
Supporting treatment to the system according to indications should be given e. g., bowels, kidneys, nerves, muscles, joints as in constipation, nephritis, neurosis, rheumatism, arthritis, endocarditis, septicemia, rhinitis etc.
Ophthalmia Neonatorum
This is an acute purulent conjunctivitis in the new-born. Neonatorum comes from a junction of the Greek word Neos—new, to the Latin word natus—born; new-born. This disease is the bugbear to the obstetrician. He must always be on the lookout for it and act promptly in order to save sight. Every general practician should make a careful study of this disease if he expects to treat children.
Sixty to seventy percent of conjunctivitis neonatorum is due to the infection with the gonococcus of Neisser. It usually comes from a gonorrheal discharge from the genitals of the mother. The nurse or anyone who handles the baby might be the agent in the transmission of the infection.
The disease is not always of gonorrheal origin. Some cases are due to the pneumococcus, streptococcus, diplobacillus or one variety of staphylococci.
Thus there are two varieties or types of ophthalmia neonatorum; a severe type which is gonorrheal or specific and a mild type which is non-specific.
In some states there is a law which requires the use of silver nitrate in the eyes of all babies at birth. Every baby’s eyes should be thoroughly washed at birth, with boric acid and where there is the least suspicion of gonorrhea silver nitrate 1% or argyrol 25% should be used. A routine use of one of the silver salts would be good practice.
Symptoms.—Gonorrheal cases begin usually the third day after birth, non-gonorrheal, on the fifth or sixth day. Both eyes are usually involved, one worse than the other. The lids swell much. There is chemosis of the conjunctiva which may put the cornea in a pit. The discharge is abundant. It is yellow or greenish yellow.
The disease gradually declines and the discharge ceases in six to eight weeks. The conjunctiva is thickened and looks granular. May be some cicatricial changes.
The chief danger is to the cornea, more so if it becomes hazy the first two days. Corneal lesions seldom occur in non-specific forms.
If the cornea is involved perforation is likely, with a general inflammation of the eyeball (panophthalmitis) followed by atrophy (phthisis bulbi).
Complications such as rhinitis, meningitis, endocarditis and general septicemia may occur.
Diagnosis is made from the onset, character, symptoms and course with the use of the microscope.
Prognosis.—Delayed or improper treatment in these cases will likely be fatal to sight as sloughing of the cornea will occur. With prompt and proper care the prognosis is favorable.
Treatment.—Mild cases (non-specific) are treated in the same manner as simple conjunctivitis. In severe cases (specific) clean the eye carefully and apply cold compresses of gauze 15 to 20 minutes at a time every hour or two. Keep the gauze on a block of ice and change every few minutes. If the cornea is involved heat may prove more satisfactory. There must be constant removal of the discharge. Wipe away the excess and irrigate freely with boric acid at least every hour day and night and more often if necessary. After each washing use a solution of argyrol 25%. Once a day silver nitrate 1% solution may be used and washed out with a salt solution.
If the cornea should ulcerate the treatment need not be altered.
The attendants should be carefully instructed as to the importance of the care and the contagious nature of the pus.
Antisepsis and cleanliness here is more essential, effective and exclusive than in any other disease of the eye. Wisdom in the use of antiseptics is a strong point in the armamentarium of every progressive osteopath.
Trachoma
This disease is known as granular lids or granular conjunctivitis. Although the germ has not been discovered, we know this is an infectious disease. A roughness and hypertrophy of the conjunctiva develops. There is development of follicles or granulations. Later these products are absorbed and cicatrization of the tissues follows.
Cause.—Trachoma is found most common in Egypt and Arabia. It spreads easily in crowded institutions. It is in many instances a mixed infection with the Morax-Axenfeld bacillus, Koch-Weeks bacillus and the gonococcus.
“Trachoma bodies” have been discovered which are claimed by some to be a causative factor in the disease. These small bodies are not found in all cases however.
Spinal lesions of the cervical and upper four thoracic vertebræ will disturb the blood and nerve supply to the eye which will predispose to the disease should some of the virus or germs of trachoma be present. In practically all these cases there is tenderness if not an actual twist at the second and third thoracic.
Symptoms.—A small boy came to our clinics complaining that his left eye was smaller than the right. No inflammation or swelling was prominent. The eye looked normal except slightly smaller than the right. On turning the lid granules in the fornix of that eye were readily noticed. Trachoma had a good start. The tissues were so hypertrophied in that region that the eye could not be opened quite as wide as the other one, hence the impression that that eyeball was smaller. The granulation often develops so insidiously that the victim may have the disease for months before he realizes he has a bad eye. When symptoms appear there may be photophobia, lachrymation, gluing of the lids from a scanty secretion, pain, and blurring of vision. The granules are gray, translucent and roundish under the conjunctiva.
Hypertrophy increases to a certain height when cicatrization and contraction begin. The duration may be years. The more the hypertrophy the longer the duration and the greater the contraction. (Note here that treatment should be directed toward combatting the hypertrophy by establishing circulation).
Sequelæ. I merely mention the sequelæ here: pannus, ulceration of the cornea, trichiasis, dystrichiasis, entropion, ectropion, symblepharon, xerosis, corneal opacities. For the explanation, pathology and treatment of these sequelæ not covered in this treatise, see any good works on diseases of the eye as Weeks, Fuchs or De Schweinitz.
Treatment of Trachoma.—In reporting cases of trachoma treated and cured by osteopathy we should be sure of our diagnosis.
The treatment is antiseptic, hydrotherapeutical, osteopathic and operative. A saturated solution of boric acid should be used. Argyrol 20% is good if there is much secretion. Nitrate of silver 2% and copper sulphate are still used in some cases to advantage as claimed by some physicians. The osteopath should count on careful cleanliness.
Hot compresses over the eyes are often very agreeable.
Operations are often performed for trachoma. The granules are rolled out with Knapp’s roller forceps, and other methods.
Grattage is practiced with some wonderful results. It is done as follows: Get some fine sand paper and cut it in strips about one-half inch wide by three or four inches long. Put it in alcohol in a vessel for ten to fifteen minutes. Pour off all the alcohol except a few drops that will cling to the vessel by capillary attraction. Touch a match to the residue. This will burn just enough to make the sand paper absolutely sterile without burning the latter. Put the patient under somnoform. Use a small artery forceps to grasp the edge of the eyelid, roll the lid back over the artery forceps to expose all granulations clear to the fornix. Use a protector to the eyeball. Now with the sandpaper quickly scrape or curette away all of the trachoma bodies and granulations. Repeat the process on the other eye if it is involved. Wash out well with a saturated solution of boric acid and bandage the eyes for a few hours. This will cause considerable swelling and inflammation. Use cold applications and keep the eyes disinfected. I have seen some very good results from this method.
Osteopathic.—Following the sand paper operation a thorough treatment of the cervical and upper dorsal region would add considerably to the rapidity of the patient’s recovery and sense of well being. General tonic treatment is of special benefit in nearly all trachoma cases as they are subnormal in their general health.
One form of technique which has been used by myself and others to advantage in these cases is as follows: Sterilize the fingers carefully, lubricate with vaseline or K. Y. the forefinger of the right hand. With the left hand raise the upper lid and introduce the forefinger of the right hand with the thumb above. Catching the lid between the thumb and finger squeeze and massage the whole structure clear to the fornix as thoroughly as possible. Repeat the process on the other eye.
A technique used by Dr. Edwards of St. Louis is as follows: After sterilizing and lubricating the forefinger lift the lid and introduce the finger as far as possible into the orbit pushing the fornix back into the orbit. This stretches all the tissues around the fornix, opening up a better conjunctival and palpebral circulation. The ciliary vessels and nerves are stretched and stimulated. It is rather surprising to one who has not tried it, how far the finger can be introduced into the orbit.
One set of nerves that should be especially studied and considered in trachomatous conditions is the cere-brobulbo-spino-sympathetic-ciliary arc. This has already been elaborated. All spinal lesions should be carefully diagnosed and corrected.
Dr. T. J. Ruddy’s third finger eye instrument is very useful in these conditions in restoring normal circulation about the orbit.
See that the nose and throat are normal.
Phlyctenular Conjunctivitis
By some this disease is considered an eczema of the conjunctiva. This will at least enable us to get an idea of the conjunctival pathology. What is said of phlyctenular conjunctivitis applies largely to its corresponding disease of the cornea-phlyctenular keratitis. Scrofulous ophthalmia is applied by some because so many of these phlyctenular patients have scrofula. Herpes conjunctivæ is used as a name because of the small blisters or blebs that form in the beginning stage. Little red eminences develop near the limbus (sclerocorneal junction). They are cone shaped, slightly elevated about the surrounding tissue. There may be one or several, usually not more than one or two. After a few days the cone breaks and on top appears a small gray ulcer. There is further breaking down and the cone disappears leaving an ulcer on level with the conjunctiva. Vessels are congested about it. There may often be noted an area of small vessels, fan like in shape, running from the outer region of the conjunctiva to the ulcer or phlyctenule.
Etiology.—This is a disease of frequent occurrence in children, mostly among the poor classes. Such things as eczema, dirt, adenoids, scrofula, rhinitis, malnutrition, abuse of tea and coffee and exanthematous disease are mentioned by oculists as causes. I have no doubt any or all these conditions predispose to phlyctenular conjunctivitis.
De Schweinitz in “Diseases of the Eye,” 1916 edition, p. 242, says: “The exact cause of ocular lesions, or phlyctenular eruption, has not been determined.”
I have met Dr. De Schweinitz and heard him lecture on the eye. I consider him one of the best eye specialists in the country. His experience and study with the eye dates over many years and his book has gone through eight editions. He is professor of ophthalmology in the University of Pennsylvania; Ophthalmic Surgeon to the Philadelphia Polyclinic Hospital, the Philadelphia General Hospital etc., etc.
His opinion represents the summary of the investigation of the ophthalmic profession the world over and through all the past down to the present time. “The cause of phlyctenular conjunctivitis is not known.”
Bacteriology.—At times in the ulcers have been found the staphylococcus pyogenes aureus and albus. They are also found in a normal conjunctival sac. They could not with logic be taken as a causative factor; at least they would be only secondary.
If oculists and other students of the eye all had a good deep osteopathic vision to throw light upon these problems many causative factors would take on a new meaning. Such supposed causes as have been mentioned, e. g. eczema, adenoids, rhinitis and malnutrition may easily be secondary to the osteopathic lesions. Micro-organisms may be enabled to act because of trophic and circulatory disturbances to the conjunctiva through disturbed nerve connections from lesions in the cervical and upper dorsal regions. Herpes zoster is purely a trophic nerve disturbance manifestation on the skin as blebs or blisters with more or less neuritis. Any lesion that would affect the integrity of the function of the fifth cranial nerve might easily manifest itself as herpes of the conjunctiva.
We believe the osteopathic lesion is primary and fundamental in the causation of most of our phlyctenular conjunctivitis. Of course insanitation, scrofulous diathesis and the exanthemata play their role. A good diagnostician should figure out the relative importance. The history, onset and examination will usually eliminate these conditions.
Symptoms.—Lachrymation, photophobia, blepharospasm and injected vessels are the chief symptoms. There is pain as well as fear of light. The child fights examination.
The attack subsides in ten to fourteen days unless there is multiplicity of blebs. Some patients have repeated attacks for months or years. Many of these cases in medical clinics keep coming for months with repeated attacks. Never leave out careful osteopathic treatment.
Prognosis.—This is favorable for a final cure. If there should be multiple blebs and frequent recurrence and the cornea is invaded, the prognosis is not good for perfect sight. The pathology goes deep enough to affect Bowman’s membrane of the cornea disturbing the substantia propria. This causes a macular condition of the cornea which impairs sight.
Therapy.—Diet should be bland; the eyes should be protected from irritants; yellow oxide ointment should be used in the eye once a day or 10% argyrol. The ointment is preferred. Moist warm compresses on the eye are comforting. A boric acid wash in almost all conjunctival trouble is good. If there is much irritation giving a suspicion of iris involvement a drop of atropine ½% should be used. The general regimes of living should be regulated.
Osteopathic treatment should be directed toward building up the general health and correcting all lesions, especially that may have a specific bearing on the eye trouble. Such lesions will be found more often at the first, second and third thoracic, but may be anywhere from there to the occiput.
Vernal Conjunctivitis
This disease is known by many as vernal catarrh or spring catarrh of the conjunctiva. It is a chronic inflammation which sets up changes in the conjunctiva and tarsus. This disease may be confused with trachoma unless one observes closely. There are broad flat papillæ on the conjunctiva. These papillæ may readily be taken for granulations. They are larger than the granules in trachoma. They somewhat resemble the arrangement of cobble stones. The conjunctiva has a bluish-white filmy appearance called by some, milky shimmer.
The disease was thought at first to appear only in the spring, hence the name vernal. Many cases continue through the year with exacerbations in the spring. It occurs more often in boys. Both eyes are attacked. It may heal and leave no trace. It may last from four to twenty years.
Causes.—Almost all works on the eye say the cause is not known. De Schweinitz says, “Definite information in regard to the cause of this disease is lacking.” There may be a micro-organism which has not been discovered.
I wish to call the attention of the osteopathic profession to the great fact that there are numbers of diseases of the eye as well as of other parts of the body about which the medical profession are entirely “at sea.” This gives valuable ground for scientific research by our profession.
My experience with this disease is not sufficient for me to speak with any positiveness or finality as to its cause. The altered trophic parts and the very chronic condition existing leads me to the firm belief that we will ultimately find the cause as a mechanical lesion affecting the trigeminal or sympathetic (or both) nerve connections. Glare of light and local irritants act only as secondary causes. Nasal disease may be associated and act as a cause.
Symptoms.—There is photophobia, some mucus, slight pericorneal injection, redness of the conjunctiva of both the bulb and lids; that of the lids is thickened and of dull pale color due to sub-epithelial hyaline thickening. The fact that there is no pannus, and flat granulations and recurrence with spring, marks it from trachoma.
Prognosis.—Under medical treatment it is unfavorable; may last twenty years. Slight opacity of the cornea may develop.
Treatment.—The eyes should be protected with dark glasses. Cold compresses give some relief. Boric acid is good as a wash. Yellow oxide of mercury ointment may be of service as an antiseptic and alternative. If nasal disease exists, it, of course, should be treated according to indications. Fundamentally the lesions in the spine in the cervical and upper dorsal regions should be specifically corrected. When enough cases of vernal catarrh have been observed and treated osteopathically much light and benefit will be brought to bear upon this obscure and intractable disease of the conjunctiva.
Diseases of the Cornea Anatomy
The cornea with the sclera forms the outer coat or tunic of the eye ball. The cornea is in front and forms one-sixth of the envelope. It is a segment of a smaller globe than that of the sclera. It is about 12 mm. horizontally and 11 mm. in the vertical diameter. Its thickest part is at its junction with the sclera where it is about 1 mm. This junction is called the limbus. The cornea is inserted into and rests on the sclera like a watch crystal. The fibers of the cornea pass continuously into the sclera, however. The normal cornea is transparent. Most morbid changes of the cornea cause a diminution in this transparency. In old age a narrow gray line near the corneal margin makes its appearance. This is known as the arcus senilis. There is a little strip of perfectly clear cornea between the arcus senilis and the limbus.
The cornea has five layers. These layers should be noted with care, as in wounds of the eye, foreign bodies in the cornea and ulcerations, the results depend much upon which layers are affected.
1. The anterior epithelium consists of pavement cells of several layers. This layer of the cornea may be damaged or scratched off in large patches and still it will heal readily leaving no trace of the injury.
2. The anterior elastic lamina or Bowman’s membrane is very thin and homogeneous; it is just beneath the epithelial layer and forms a resisting sheath to prevent damage to the next layer.
3. The stroma or substantia propria. This layer composes about nine-tenths of the cornea. It is composed of minute connective tissue fibers between which lie some stroma cells or corneal corpuscles. Some of these cells are fixed while others are motile. The motile ones are the white blood-corpuscles which move about in the lymph passages of the stroma. They increase in any irritation of the cornea.
4. Descemet’s membrane. This is a tough homogeneous hyaloid membrane back of the stroma. When the stroma is diseased and breaks down Descemet’s membrane may be sufficient to prevent a puncture of the cornea.
5. The Endothelial layer is a single layer of flattened cells which coat the posterior surface of Descemet’s membrane.
The margin of the cornea is in relation with three membranes, the conjunctiva, the sclera and the uvea (iris and ciliary body). In a disease of the cornea, a conjunctivitis, an iritis or a cyclitis is easily started.
The cornea contains no vessels. It is nourished by imbibition. At the limbus there is a rich network of marginal loops supplied by the anterior ciliary vessels. From these loops the blood plasma passes into the stroma of the cornea.
The nerves of the cornea come from the ciliary nerves and the nerves of the bulbar conjunctiva. These are from the trigeminus and the sympathetic. The nerves extend numerously in the stroma passing forward through Bowman’s membrane into the epithelial layer. This makes the cornea very sensitive to the touch.
Examination of the Cornea
Note the size and form. Both may be modified by morbid processes. Note the surface with regard to curvature, evenness and smoothness. In keratoconus the curvature is greatly increased. Noting the reflex images in the cornea and comparing these with those of a normal cornea will show any variation in curvature. Also any unevenness of the surface may be noted by the irregularity or distortion of the images. Uneven spots on the cornea may be depressions or elevations from loss of substance; wrinkles or collapse from lowered tension.
If the smoothness or polish of the cornea is lost it looks like glass that has been breathed upon or greased. It is lusterless and dull.
Note also the transparency of the cornea and determine the form, extent and density of the opacity; whether it is diffuse or in spots; in the deep or superficial layers. A magnifying glass should be used in the study of opacities. According to the density of the opacity of the cornea it is known as a nebula or a nebulous opacity, a macula or a leucoma. The nebula is the least noticeable and the leucoma is the densest opacity. A leucoma is a condition of complete opacity. The cornea looks white.
Defects in the corneal epithelium may be made to show clearly by the use of a 2% solution of fluorescein which stains them green.
Note the sensitiveness of the cornea by touching it with the end of a thread, a little cotton or a shred of paper. The sensitiveness is diminished or lost in glaucoma and some other diseases.
Diseases of the Cornea
Almost all diseases of the cornea have some form or degree of inflammation. Keratitis is the word generally used for inflammation of the cornea. In order to aid clearness in discussion there are various subdivisions of keratitis made by different writers. Suppurative and non-suppurative are the principal types. In suppurative keratitis there is always some destruction of corneal tissue which on healing leaves an opacity with partial loss of vision. Germs gain entrance into the tissues usually from the exterior and some form of ulceration results.
The following classification is taken from Fuchs:
Suppurative Keratitis.—(1) Ulcer of the cornea; (2) Serpiginous ulcer; (3) Keratomalacia or Xerosis; (4) Keratitis neuroparalytica.
Non-suppurative Keratitis.—(A) Superficial: (1) Pannus, or keratitis with blood vessels; (2) Phlyctenular, or keratitis with vesicles. (B) Deep: (1) Parenchymatous or interstitial.
In keratitis there is first an infiltration or the increase of cells in the substantia propria or the parenchyma of the cornea. This is the exudate of the inflammation. It causes the cornea to look more or less dull or cloudy. The disease may clear up at this point or go on to suppuration. If it clears up it is known as resorption. If the lamellæ of the substantia propria are not destroyed by the process, resorption takes place with no loss of substance. The exudate disappears and there is perfect transparency of the cornea again. There may be slight damage of the stroma preventing perfect transparency. Resorption of the exudate may not be quite complete which may become partly organized and left permanently fixed in the cornea. Cases resorbing without destruction of the stroma are forms of the non-suppurative keratitis group.
If the stroma breaks, suppuration occurs. This is the second stage and is associated with a localized destruction of the cornea. These cases are known as suppurative keratitis or ulceration of the cornea. The disintegration begins in the most anterior layers of the cornea. A slight depression in the cornea can be noticed. The infiltration is all about the ulcer, getting less as it is more remote from it. If the floor and walls of the ulcer are foul with the infiltrate it is known as a progressive ulcer. Sloughing may continue to spread the ulcer.
If the cloudiness around it disappears and the ulcer acquires a smooth transparent base and edges it is known as a retrogressive or clean ulcer.
The disintegrated areas of the cornea may be replaced by newly formed tissue. This is the third stage or that of cicatrization. This new tissue is connective tissue. It is opaque, leaving a permanent opacity.
Stages of keratitis:
Suppurative.—(1) Infiltration; (2) Suppuration and (3) Cicatrization or Reparation. The suppuration is progressive or retrogressive.
Non-suppurative.—(1) Infiltration; (2) Resorption.
In the diagnosis of a keratitis one should look at it very carefully. A loupe which has thick plus sphere lenses will magnify the field and may be of great assistance in observing closely the condition.
If the cornea is clouded and dull the trouble is recent and if there is no loss of substance it is an infiltrate (first stage). If there is loss of substance it is a progressive ulcer (second stage.)
If the surface is lustrous but cloudy the trouble is an old one and if there is loss of substance it is a retrogressive ulcer; if no loss of substance it is a cicatrix.
Frequently blood vessels grow in from the margin in ulcerations of the cornea. This is usually a process of healing of the corneal ulcer. The advent of the blood vessels is favorable. After healing the blood vessels gradually disappear. They never entirely disappear from large cicatrices.
In some cases new vessels accompany the inflammatory process and like the exudate are a part of the clinical picture of the disease as in parenchymatous or interstitial keratitis. Pannus also has vessels. They are not in the cornea but are in new tissue deposited upon it.
Symptoms appearing in keratitis:
1. Ciliary injection or a red area encircling the cornea. If the keratitis is severe there will be considerable inflammation of the conjunctiva which may hide to some extent the ciliary injection.
2. Iritis or iridocyclitis may set in. The iris and ciliary body are in such intimate relation with the cornea that these structures are very subject to involvement in any severe keratitis. With iritis would come danger of synechiae or adherence of the iris to the anterior surface of the lens.
3. Hypopyon.—In suppurative keratitis there is some exudate into the anterior chamber of the eye. This exudate drops to the bottom of the chamber and looks like pus had gathered in the bottom of the aqueous. This condition is called hypopyon.
4. Other symptoms which are frequently prominent are diminished vision, pain, photophobia, excessive lachrymation and blepharospasm. Edema of the lids and conjunctiva may occur.
Intelligent treatment of keratitis of course is based upon the exact conditions present. Great care in diagnosis and treatment should be exercised.