Inflammation of the cornea sets in from some cause. There is an
infiltrate into the substantia propria. A spot becomes cloudy and the
surface over it becomes dull; at this point the epithelium breaks
down or exfoliates and the loss of substance in the parenchyma is the
beginning of an ulcer.
=Cause.=—The cause may be constitutional or local. The causes usually
thought of from the medical standpoint may be noted in such books as
“Diseases of the Eye” by De Schweinitz or Weeks. I wish especially
to call attention to the fact that there is frequently a primary and
underlying cause of corneal ulcers not mentioned in any medical texts,
i. e. the osteopathic lesion. By this I mean more than the spinal
lesion although the subluxation lesions that result from the occiput
to the fourth dorsal are of most importance. Any tension or change of
tissue in the cervical region that may interfere with perfect freedom
of circulation of blood to the tracts and centers in the cord, is to be
considered. The osteopath of course should take into consideration all
causes primary and secondary and govern himself accordingly.
=Symptoms and Course.=—There is a gray area surrounding the ulcer
at first, also the floor is grayish in color. In this condition it
is known as a =progressive= ulcer or a =foul= or =unclean= ulcer.
This cloudiness or gray area may increase in size and the ulcer keep
spreading, or it may go deeper even to perforation of the cornea.
Some ulcers advance or spread on one side and heal on the opposite
side so that they creep along on the cornea—these are the so-called
=serpiginous ulcers=.
With corneal ulcers there is irritation, pain, photophobia and
increased lachrymation. There is usually some ciliary injection which
is an indication of involvement of the iris and ciliary body. If
iritis occurs there is contraction of the pupil with slow reaction.
=Hypopyon= may develop. With iritis and the exudate there is likely to
be adhesions between the iris and the lens known as posterior synechia.
A few corneal ulcers are asthenic and do not have irritative symptoms
and yet are dangerous.
When the ulcer begins to heal it is called =retrogressive=. Dead
tissue is cast off; other tissue becomes transparent from resorption.
We have a =clean= ulcer. Symptoms disappear and cicatrization begins.
Vessels extend to the ulcers and soon it is leveled up with the corneal
surface. Cicatrization may leave it slightly below the corneal level or
above it.
If there should be perforation of the cornea from the ulcer there may
be =complications=, e. g. keratocele, loss of aqueous, dislocation
and expulsion of the lens, intra-ocular hemorrhage, flattening of the
cornea, fistula of the cornea, glaucoma, intra-ocular suppuration,
prolapse of the iris into the opening, etc. These complications and
sequelæ that occur occasionally will not be considered here.
After healing is complete by cicatrization there is opacity of the
cornea in proportion to the depth and size of the ulcer. In months
and years of time there is some clearing of the opacity so that small
superficial opacities may become invisible.
=Treatment of Corneal Ulcers.=—Most ulcers of the cornea are quite
amenable to proper treatment and the prognosis is favorable. Neglect
or wrong treatment is very dangerous. The treatment is local and
constitutional. Often the ulcer is kept going by unwholesome
constitutional conditions.
=Local Treatment.=—This varies according to the stage of the ulcer,
whether progressive or retrogressive. In a progressive or foul ulcer if
due to trauma any foreign bodies should be removed. If the ulcer is a
result of pathology of the conjunctiva it is of primary importance to
treat the conjunctival condition.
In mild cases of ulcer a dressing over the eye with atropine ½% to keep
the pupil dilated is sufficient local treatment. The bandage protects
the eye from bright light and other environment and the atropine puts
the iris and ciliary body at rest preventing complications and giving
nature her best chance to work.
If the ulcer is rapidly progressive, warm compresses an hour or two a
day are good; iodoform sprinkled on the ulcer or actual cautery may be
used. In the retrogressive stage (clean ulcer) healing has begun and
we desire to get as near as possible a resistant transparent cicatrix.
Yellow oxide ointment is useful at this stage.
=Osteopathic.=—The local measures just mentioned are not incompatible
with osteopathic theory or practice. They are merely adjunctive in
getting nature’s reaction toward normalization, as also are hot and
cold applications. Osteopathy comes in now in a most important and
fundamental way with the constitutional and specific lesion treatment.
The =bulbo-spino-sympathetic-ciliary arc= has been mentioned and
explained. Through this important nerve connection with the eye,
profound and wholesome effects on the eye may be gotten by osteopathic
treatment. Frequently lesions of the occiput, cervicals and upper
dorsals will affect the integrity of the ocular structures through
disturbances of nerve and blood supply.
The stomach, bowels, liver and kidneys should be carefully noted
in corneal ulcers. Poor circulation, indigestion, constipation and
auto-intoxication may have an important bearing on the recovery of the
ulcer.