considerably advanced in life. The cone has its apex in the centre of
the organ, seems thick and crystalline when viewed laterally, and when
looked on from the front has a sparkling appearance. In some cases it
is opaque in the centre, and occasionally its surface is irregular.
Vision of objects at any distance is very indistinct; those placed
within an inch or two of the eye are most distinctly seen, especially
if looked on through a small aperture. The disease usually affects both
eyes, though not always in an equal degree. The patients cannot judge
accurately of distance, and see objects multiplied and disfigured.
[Illustration]
_Staphyloma_ has been already alluded to as an occasional consequence
of purulent ophthalmia in children. The cornea is thickened, prominent,
and opaque; and in most cases vision is either much impaired or
entirely lost. The prominence varies in different cases, being
sometimes very little elevated beyond the natural state of the part,
while in other instances it protrudes from between the eyelids. After
having attained a certain size it often becomes stationary; but very
frequently it continues to enlarge gradually. When the prominence is
large, much inconvenience arises from the eyelids not being allowed to
close; and the eye, being thereby deprived of its natural covering, is
extremely liable to become inflamed from external irritation. When one
eye is affected with staphyloma, the other not unfrequently becomes
similarly diseased.
Dropsy of the anterior chamber, or _Hydrophthalmia_, occasionally takes
place in persons of weak constitutions. The aqueous humour is either
secreted in greater abundance than it usually is, or absorption is
diminished. The cornea gradually accommodates itself to the increase
of the fluid behind, and becomes wider and more prominent, but retains
its transparency; in looking at the eye, the anterior chamber is seen
evidently enlarged, and occasionally the aqueous humour is of a turbid
appearance. There is little or no pain in the eyeball, but the patient
complains of an annoying sense of fulness and tension in the part. In
consequence of the vitreous humour also accumulating, the whole organ
is ultimately enlarged considerably, and its motions are thereby much
impeded. At first, vision of near objects is impaired, whilst the
patient sees very distinctly those placed at a distance; ultimately
sight is entirely lost.
_Exophthalmia_, or protrusion of the eye, attends the preceding
disease, and is also a consequence of various other morbid actions
in the globe and its neighbourhood, especially from the pressure of
tumours in the orbit. The chronic enlargement of the bulb is noticed
more fully in the succeeding chapters.
_Treatment of External Ophthalmia, and its Consequences._—The exciting
cause, if such exist and can be discovered, ought in the first place
to be removed. The surface of the organ and of the palpebræ should be
carefully examined, either with the naked eye or with a magnifying
glass, in order to detect any small extraneous body which may be
lodged in the part. In examining the inner surfaces of the palpebræ,
it is necessary, to produce complete eversion, to bring the parts
completely into view; and the most convenient method of accomplishing
this is to lay hold of the ciliæ between the finger and thumb, and
reflect the lid over a silver probe placed along its base. This can,
by a little practice, be accomplished readily without using a probe,
and even by the fingers of one hand only. This is the more necessary,
as small particles of foreign matter lodge more frequently on the
palpebral conjunctiva than on any other part. If a particle of glass,
metal, stone, &c., be discovered, it should be gently removed by the
flattened extremity of a silver probe, or by a scoop, a fine needle,
or a delicate brush. In some cases washing the surface by means of
a small syringe, filled with a bland fluid, is extremely useful; as
when an impalpable powder has been thrown into the eye, and can with
difficulty be removed, in consequence of spasmodic contraction of
the eyelids preventing exposure of the parts. The application of an
emollient poultice, with the addition of hyoscyamus, is beneficial when
it has been found impossible to remove the whole of a fine powder. When
particles of lunar caustic have, by accident, come in contact with
the eye, they are to be removed, as soon after insertion as possible,
by a fine hair pencil dipped in oil or fresh butter,—not in water.
Small loose bodies are generally carried, by the increased lachrymal
secretion, along the sulcus formed by the apposition of the eyelids,
to the inner canthus, and there discharged. And, in order to favour
this natural process for removing extraneous matter, the patient should
be directed to keep the eyelids shut, and as quiet as possible, to
cover them with his hands, and to blow his nose forcibly: thus the
greater number of the extraneous particles will be got rid of. Those
which remain lodged in the membranes must be speedily removed by those
artificial means which have been already enumerated. If entropion is
the cause of the inflammation, the eyelashes are either plucked out,
or completely destroyed by removal of their roots. The inflamed organ
should be carefully protected from the stimulus of strong light; the
patient is to be placed in a darkened room, and the eye protected by a
thin green shade. The shade, however, may be worn too long, so as to
induce an extremely weak and tender state of the organ.
If there be good grounds for believing that the incited action has
been caused by suppression of any discharge, that should be encouraged
to return, and the cause of the suppression must be avoided. If a
gonorrhœa have been suddenly arrested by the employment of stimulating
injections, these must be instantly discontinued; and some have even
gone so far, in such cases, as to introduce bougies impregnated with
gonorrhœal matter, in order to procure a renewal of the discharge.
In cases of suppression of purulent discharge from the ears, or the
surrounding parts, followed by external ophthalmia, a blister or
sinapism should be applied in the neighbourhood of the part from which
the discharge formerly issued. When the menstrual evacuation has been
arrested, leeches and fomentations should be applied to the pudenda, or
around the anus, and emenagogues administered internally; the patient
should be placed in a quiet and well ventilated apartment, and kept
free from any emotions of the mind; all noise and other sources of
irritation should be studiously avoided.
If the incited action in the eye do not subside, as it often will
not, on removal of the exciting cause, recourse must immediately be
had to very active means for its subjugation; for in no other organ
does inflammatory action proceed more rapidly to an unfavourable
termination. By timely use of antiphlogistic means, those consequences
of external ophthalmia, which we have already treated of, may be
avoided; and, with respect to most of them, it is much better to
prevent their occurrence, than combat them after they have been allowed
to take place. The eye is more valuable to a great proportion of people
than a limb; and the surgeon is very culpable if he be not master of
this part of his profession, and able to undertake the management
of every disease and accident to which the eye is liable. “In cases
of inflammation the general treatment is the same; but each variety
requires peculiar attention during the cure, depending on the structure
and function of the tissue affected.”
In the _first stage_ of external ophthalmia, active antiphlogistic
measures must be put in force. In full habits, and cases of intense
action, general bleeding must be employed, even to fainting, from the
veins of the arm or of the neck, or from the temporal artery,—and
repeated, if necessary, according to circumstances. Blood is sometimes
abstracted by cupping from the temples or the nape of the neck; but
it is a painful and uncertain mode of emptying the vessels. Local
bloodletting, in many cases, suffices to moderate the action; in all
it is most beneficial and important, after the employment of general
depletion. The application of leeches to the inner canthus is the most
effectual method of abstracting blood locally, as at that point the
venous return is made from the eye. If placed on the temples, they can
produce very little benefit; if on the outer surface of the eyelids,
ecchymosis follows, on account of the extreme looseness of the cellular
tissue in that situation. Or the angular vein, at the inner canthus,
may be opened with a lancet, and a considerable quantity of blood
thereby abstracted from the seat of the disease. Leeches applied to the
conjunctiva of the lower lid are sometimes advantageous; but leeching
and scarification are more useful in the chronic stage: and the latter
is injurious in acute ophthalmia. Saline purgatives, and antimonial
medicines, a very material part of the antiphlogistic regimen, must not
be omitted. Enemata, with occasional pediluvia, are much recommended
by some Continental writers. In bilious habits emetics, followed by
mercurial purges, will be found very useful. With respect to topical
treatment, warm applications are found to afford decided relief in
the first stage, and are, in consequence, generally used. By some,
however, cold water, or water with vinegar, is applied from the first.
Poultices, whether warm or cold, prove annoying from their weight. Warm
fomentations, simple or anodyne, are preferable, and may be repeated
according to the feelings of the patient; or the eye may be exposed to
the steam of water.
When by these means the violence of the symptoms has abated, as
usually happens in the course of a very few days, the organ must be
gradually accustomed to its natural stimulus, light. The shade must be
discontinued, and the room no longer darkened; and now leeching becomes
of great service, while the evacuation is to be followed by gently
stimulating or astringent applications, so as to produce contraction of
the still dilated, though partially emptied, vessels. Various collyria
may be employed for this purpose. Solutions of the sulphate of zinc,
of muriate of mercury, of sulphate of alum, of acetate of lead, or of
the lapis divinus—wine of opium—the citrine ointment, or the unguentum
oxydi hydrargyri rubri, &c.—or stimulating vapours of various kinds.
Camphor is a good addition to many of the applications. The collyria
may be cold, or slightly warmed; and maybe dropped into the outer
canthus, flowing over the eye, and escaping by the inner canthus,
according to the natural course of the fluids of the eye; or they may
be inserted at the inner canthus, the head being immediately afterwards
inclined so as to allow the fluid to pass towards the external canthus;
or they may be applied by means of an eyeglass. Warm fomentations,
and other relaxing remedies, however useful during the first stage,
are worse than useless, are hurtful in the highest degree, when the
affection has passed into a chronic state; as also are antiphlogistic
means, and exclusion of light,—remedies so essentially necessary in the
first stage.
In ophthalmia, attended with profuse _purulent_ discharge, the
structure of the eye is in great danger of being destroyed, from the
intensity of the action, and its liability to extend to the deep parts
of the organ; the most active practice is required from the first.
Copious general depletion, ad deliquium, must be quickly had recourse
to; and the patient must be freely purged, and kept in a state of
partial nausea for some time, by exhibition of antimonials. After
general bloodletting, the repeated application of leeches to the inner
canthus is necessary, in order to empty sufficiently the vessels of the
part. Where the chemosis is so extensive as to bury the cornea, as it
were, beneath the folds of the swollen conjunctiva, sloughing of the
transparent tunic is frequently threatened. In order to arrest this
fatal result, much good is often obtained by division of the chemosis.
A sharp-pointed bistoury is passed through the swollen membrane, and
radiating incisions practised, commencing at the corneal margins, and
directing them towards the circumference of the globe. Sometimes four
or even five of such divisions are called for, while care is taken not
to wound the sclerotic coat beneath. A considerable quantity of blood
is sometimes lost by this procedure, and, the chemosis subsiding,
the cornea is saved. Infusion of tobacco, solutions of acetate of
lead, and nitrate of silver, æther and laudanum, have been used as
applications to the eye from the very commencement of the affection;
but the propriety of the practice appears very questionable. Blistering
the nape of the neck proves highly beneficial, after the employment
of the antiphlogistic measures; and in many cases it is necessary
to keep up discharge from the blistered surface for some time. On
subsidence of the violent symptoms, the swelled conjunctiva is to
be attacked with escharotics and stimulants, as the nitras argenti,
sulphas cupri, or various collyria: then only can such applications be
advantageous; at an earlier period they must do harm. They repress the
exuberant granulations which may have formed, or may be forming, on the
conjunctiva of the eyelids, promote contraction of the dilated vessels,
diminish the relaxation of all the tissues, and stimulate the now
dormant action of the part into a healthy state of excitement. Gently
stimulating collyria may be injected betwixt the lids, by means of a
small syringe. In granulated conjunctiva, it is sometimes necessary to
remove a greater or less part of the diseased membrane by escharotics,
the knife, or scissors; and after this has been accomplished it is
well to encourage bleeding to a slight extent. In removing part of
the palpebral conjunctiva, care must be taken to avoid injuring the
cartilage of the tarsus; and, in the lower lid, not to take away too
large a portion, lest entropion should occur during cicatrisation. In
hospital practice, the infected should be separated from the healthy;
and promiscuous use of towels and sponges must not be allowed.
In _Purulent Ophthalmia of Children_, antiphlogistic means must
be pursued, if the patient is seen during the first stage of the
disease; but children do not bear depletion well. After the discharge
is established, the surface of the eye must be kept free of matter,
by frequent injection of a bland, tepid fluid; and stimulating or
astringent collyria should be applied three or four times a-day.
When _Inflammation of the Cornea_ is established, it is exceedingly
difficult to procure contraction of the vessels. Active antiphlogistic
measures must be employed in the acute stage; and in the chronic,
stimulant applications are to be had recourse to. As, however,
corneitis is frequently kept up in its chronic form, from deficient
constitutional power in strumous habits, strict attention must be paid
to the diet and secretions of the patient. Mild mercurial alteratives,
diaphoretics, and tonics combined, will often effect a cure, where all
local treatment has been tried in vain. When a large plexus of vessels
remain dilated on the part, the most effectual method of removal is to
divide them, as they ramify on the sclerotic, by means of scissors, or
a fine knife, and afterwards to employ stimulating applications.
The irritability of _ulcers_ on the cornea is diminished by the
application of nitrate of silver, in solution or substance. If in
solution, the application is used in the proportion of three to ten
grains of the salt to the ounce of distilled water; if in substance, a
portion, finely pointed, is gently applied to the sore, which may be
afterwards besmeared with a little oil or simple ointment, in order
to confine the action of the nitrate to the ulcerated part. It is not
necessary, but, on the contrary, hurtful, to rub the caustic freely
on the sore; a very slight application is sufficient to coagulate the
secretions on the part, and form a covering for protection of the
surface. In two or three days afterwards, when the temporary covering
has become detached, and when the irritability of the sore has in
consequence returned, it will be necessary to repeat the application,
but not till then. On each application, and few are in general
required, the sore is found reduced in size considerably. The collyrium
nitratis argenti is very useful in many obstinate cases of affections
of the eye and eyelids, the strength of the solution being varied,
according to circumstances.
In _Albugo_ and _Leucoma_, proposals have been made for excising,
scraping, or perforating the opaque part; but the cure by such means
is worse than the disease, as a raw surface is left larger than the
previous opacity, and the cicatrix which must inevitably form also
occupies a larger space, and is equally opaque. Leucoma and Albugo
are incurable diseases, though the opacities may become somewhat
thinner, by natural processes, after the lapse of a long period.
_Nebulæ_, however, are often removable. During the treatment of them,
or, rather, before beginning to treat them, it is of the utmost
importance to attend to the state of the surface of the eye, and of
the lids and eyelashes. Stimulating substances may be applied in cases
where the opacities are thin: powders of calomel, aloes, sugar, &c.,
have been blown into the eye; stimulating lotions or ointments are
preferable; one containing the nitrate of silver, with the addition
of a proportion of the liq. sub-acet. plumbi, is sometimes used
with advantage. These, however, are often of no avail, unless the
dilated vessels, when such exist, are divided, or a portion dissected
out; afterwards stimulants will be efficacious, and must be used
assiduously. The vessels may require to be divided again and again.
In _Ophthalmia tarsi_, gently stimulating ointments or lotions are to
be used, and in obstinate cases much advantage will result from the
application of blisters behind the ears and to the nape of the neck,
or from the insertion of a seton in the latter situation. In children
it is necessary to correct the state of the bowels, scarify teeth, and
remove other irritating causes to which that tender age is liable.
_Sloughing of the Cornea_ should, of course, be prevented, if possible,
by subduing the incited action before it has attained such intensity
as to overcome the power of the part. The slough is slow in separating
when the constitution has been much weakened; and sometimes tonics and
stimulants, both external and internal, are required to hasten the
process of separation. When the surface has at length become clean, the
same treatment is required as to an ulcer of the part.
_Conical Cornea._—This deformity can scarcely be cured, nor can any
optical contrivance effectually remedy the disturbance of vision.
When the apex of the cone is opaque, the removal of the pupil to the
circumference by operation affords the best chance of assisting the
sight of the patient.
When _staphyloma_ is small, neither impeding the motions of the
eye, nor preventing its being protected by the lids, no surgical
interference is called for, as the loss or impairment of vision cannot
be remedied, and as no other inconvenience than blindness is produced
by the change of form in the part. But when the diseased cornea
projects from between the eyelids the prominence must be diminished,
on account of the deformity which it occasions, and in consequence
of the eye being deprived of its natural protection of the lids, and
being thereby exposed to constant irritation. In such cases it is
necessary to take away a portion of the cornea, that the eye may be
so diminished in bulk as to retract within the eyelids; the size of
the part removed must be proportioned to the degree of protrusion. A
cornea-knife is passed into the prominence, and carried forwards so as
to transfix the part, in a direction from the external to the inner
canthus; and by the knife being carried on, with its cutting edge
looking downwards, a flap of the cornea is made. This flap is then laid
hold of by means of forceps, and removed either with the knife or with
scissors. The aqueous humour immediately escapes, and in most cases
the crystalline lens and vitreous humour are also discharged. The eye
consequently shrinks, and retracts within the palpebræ. The cut margins
of the cornea soon assume a reddish appearance—they form granulations,
the wound contracts gradually, and ultimately closes; but the eye is
necessarily much shrunk, and totally useless as an organ of vision.
Generally suppuration takes place, causing complete disorganisation of
the parts; and the preceding inflammatory action may be so intense,
and attended with so much constitutional disturbance, as to require
active measures for its moderation. Deformity may be in a great measure
removed by adapting an artificial eye to the shrivelled remains of
the natural one. When it is necessary to remove only a small part of
the cornea, the aqueous humour alone escapes, and during the cure of
the wound the patient not unfrequently enjoys a tolerable degree of
vision; but after the wound has completely closed, vision is again lost
completely.
_Hydrophthalmia_, also, is a disease in which little hope can be
entertained of materially benefiting the patient. In the slighter
cases, in which no very annoying symptoms accompany the affection,
vision may be improved by the use of optical instruments; mercurial
preparations may be employed in moderation, with the view of promoting
absorption of the superabundant fluid. When the disease has made
considerable progress, temporary relief may be obtained from puncturing
the cornea at its lower part, so as to discharge the accumulated
aqueous humour; but a cure can scarcely be expected from such a
practice, however often the paracentesis may be repeated. In the worst
cases the pain is so excruciating, and the system so much disturbed by
the local affection, as almost to warrant the destruction of the organ,
in order to relieve the patient; but, after all, even such severe
measures will most probably prove unavailing.
In _Exophthalmos_ the treatment must vary according to the
circumstances which cause the protrusion of the eyeball.
_Of Internal Ophthalmia._—Inflammation of the internal parts of the
eyeball sometimes supervenes on conjunctival inflammation, and then
the distinctive characters of the two affections are not perceptible.
When inflammatory action attacks the deep parts primarily, the external
ciliary vessels ramifying on the sclerotic coat are seen, enlarged,
shining through the conjunctiva; and, as they advance towards the
clearer part of the eye, they form a zone of a pink colour, whose
vessels run in a straight direction towards the margin of the cornea;
but between the zone and the cornea a distinct white line is often
interposed. Then large arborescent and reticulated vessels soon appear
on the white part of the eye; and from their being more superficial
than the first, and of a brighter hue, it is obvious that they belong
to the conjunctiva. They also approach the clear part of the eye,
and, if numerous, obscure the former vessels—as also the red zone and
white line—for they pass over them, and reach the corneal margins, and
often go beyond it, in continuous ramifications. The sclerotic, in
consequence, assumes a pink-red colour, and the cornea becomes dim.