PLATE I.
.
EXPLANATION OF PLATE I.
The Normal Fundus. — FIG. 1 represents the normal fundus of the left
eye as seen in the erect image. The oval is the optic disk or optic-nerve
entrance, pink in color, and with a white center, normally depressed.
The retinal vessels emerge through it, the arteries lighter and yellower,
the veins darker and more crimson in color. Around the disk the brown,
irregular margin represents the choroidal ring.
Toward the right of the figure the darker red portion indicates the
appearance of the macula. The oval lighter ring represents the retinal
reflex that surrounds the macula. It is only seen by a certain illumina-
tion, most frequently through the uudilated pupil. The larger main
branches of the retinal vessels pass above and below the macula, giving
oft' smaller branches that run in toward it, but not to its center. Each
of the larger vessels shows a light streak along its middle. This is com-
monly most marked on the arteries. The color of the normal fundus
may vary greatly from that shown.
The part of the fundus here represented (about 10 mm. on a side) is
much more than can be seen with the ophthalmoscope at any one time.
Even with the pupil fully dilated, one cannot usually see more at once
than the disk and a zone around it about as wide as the disk itself. The
actual appearance is better represented by covering the page with a piece
of black paper in which is cut a circular opening 3 or 4 centimeters in
diameter. The appearance presented by astigmatism may be seen by
looking at this figure through a strong convex cylindrical lens.
Albuminuric Retinitis.— FIG. 2 represents a case of moderate albu-
minuric retinitis of the left eye. The optic disk is a dirty red, and its
central depression is quite obliterated. Changes in the walls of one of the
arteries passing upward have rendered them entirely opaque and white
for a space. Isolated white spots, due to fatty degeneration, are scat-
tered throughout the retina, and at the macula they are arranged in a
few radiating lines. Near the upper temporal vein, and also near the
lower, are patches of lighter color, due to exudate into the retina.
These partly hide the vessels passing through them. At the upper
margin of the lower patch is a small "flame-shaped" hemorrhage.
Other small spots of dark red, representing retinal hemorrhage, are
scattered throughout the fundus. The larger retinal veins are rather
dark and wavy, and some of the smaller veins are decidedly tortuous
and irregularly dilated.
EXPLANATION OF PLATE II.
Normal Optic Disks.— FIG. 3 represents the optic disk of the right
eye presenting certain anomalies. The choroid is more piginented than
in Fig. 1. The upper temporal vein is seen to divide upon the disk before
it enters the nerve-head. At the temporal (left) side of the disk, the cho-
roidal ring is seen to include a crescent of thin, irregularly pigmeuted
choroid, which may have been caused by previous choroidal irritation
or congestion. In this crescent is seen a choroidal vessel, and from it
starts a ciliuretinal artery which passes a little way on the disk, then
turns upon itself to be distributed toward the macula.
FIG. 4 illustrates a left optic disk surrounded by a "scleral ring," the
opening in the choroid being larger than the optic-nerve entrance. It
also shows a broad deep '' physiological cup." The darker spots in the
floor of the cup are the openings or meshes in the lamina cribrosa. A
small artery and a small vein cross the floor of the cup and climb its
temporal side. The lower margin of the cup overhangs, so that some of
the retinal vessels are first seen at its edge.
FIG. 5 represents a somewhat rare anomaly of the disk, a portion of
it looking almost like the general fundus. In some cases there is no
indication of the true outline of the concealed portion of the disk, which
looks as though covered by choroid.
Abnormal Optic Disks. — FIG. 6 illustrates the cupping of the optic
disk in glaucoma, u^he depression extends to the extreme margin of the
disk, which is surrounded by a white ring, the " halo atrophy '' of glau-
coma. The sides of the cup overhang all around, except outward (to the
right) and a little downward, where one small artery may be seen to
climb out of the excavation. The floor of the cup is quite gray, aud the
meshes of the lamina are large and very noticeable.
FIG. 7 represents the optic disk of the right eye at the beginning of
an optic neuritis. The disk is red and slightly swollen, and its small
vessels are numerous. The veins are rather full and wavy. Such an
appearance might be caused by eye-strain, but in this case was due to
brain tumor.
FIG. 8 shows the appearance of the same op tic disk, several weeks
later than Fig. 7. The outlines of the disk are entirely hidden by a
swelling extending 5 D. into the vitreous. The veins are dark and
swollen ; the arteries are narrowed. Both are very tortuous at the
disk, but the arteries in other parts of the fundus were straight, while
the veins were tortuous throughout. A small "flame-shaped" hemor-
rhage is shown at the temporal (left) margin of the swelling. The
vision in this eye was still almost normal when this sketch was made,
but declined very rapidly a month later.
FIG. 9 represents a case of "consecutive optic atrophy." The disk is
a dead-white or paper-white — " white atrophy." It is devoid of small
vessels. The retinal vessels are contracted and quite irregular in caliber,
aud white lines along their margins show thickening of the vessel-walls.
Around the disk is an irregular zone of thinned choroid with irregular
pigment-deposits.
FIG. 10 shows primary optic atrophy in a case of locomotor ataxia.
The whole disk is shrunken and quite gray in color — "gray atrophy."
The retinal vessels are uniformly contracted, but the fundus is other-
wise normal.
PLATE II.
A MANUAL
DIAGNOSIS AND TREATMENT
DISEASES OF THE EYE
BY
EDWARD JACKSON, A. M., M. D.
Professor of Ophthalmology in the University of Colorado ; Emeritus Pro-
fessor of Diseases of the Eye in the Philadelphia Polyclinic ; Formerly
Chairman of Section on Ophthalmology of the American Medical Asso-
ciation ; Ex-President of the American Academy of Medicine, and
of the American Academy of Ophthalmology and Oto-Laryngol-
ogy, and Member of the American Ophthalmological Society
SeconD JBDitton, CbotougblB
With IB2 Illustrations and 2 Colored Plates
PHILADELPHIA AND LONDON \ "
W. B. SAUNDERS COMPANY
1907
COPYRIGHT, 1907,
BY W B. SAUNDERS COMPANY
WESTCOTT & THOMSON. PHILADA,
W. B SAUNDERS COMPANY
PREFACE TO THE SECOND EDITION.
IN this new edition the original purpose and plan of
the work have been closely adhered to, and the size of
the book has been but slightly increased. Yet many
changes have been necessary in the way of descriptions
of newly recognized conditions, and additional considera-
tion of diseases or methods of treatment of which brief
mention formerly seemed sufficient. In a few instances
the teaching with regard to certain conditions has been
essentially modified, or to some extent reversed. But an
especial effort has been made to avoid being carried away
by those temporary enthusiasms which become so notice-
able in medical literature from time to time, only to
disappear completely a little latter. It is felt that the
permanent value of the MANUAL will be thus increased,
even though it seems to show a lack of response to the
" very latest " ideas.
The most important changes have been with regard to
some of the newer methods of diagnosis as, Testing the
Light Sense ; Mapping Central Scotoma ; Taking the
Prominence of the Eye-ball and the " Fogging Method " ;
the Account of the Mechanism of Accommodation and
Pseudo-accommodation ; Special Use of Lenses in the
Ophthalmoscopic Examination ; Changes in Refraction
with Age ; Amblyopia with Squint ; the Treatment of
Comitant Strabismus ; Diseases and Congenital Defects
of the Ocular Muscles ; Petrifying Conjunctivitis ; Special
Conditions that Influence Keratitis and its Treatment ;
Family Degeneration of the Cornea ; Uveitis in its
General Relations; Theories of Sympathetic Ophthal-
mia ; General Considerations regarding Diseases of the
4 PREFACE TO THE SECOND EDITION.
Retina; Macular Atrophy of the Retina; Obstruction
of the Retinal Vessels ; Developmental Alexia (Con-
genital Word Blindness); Persistent Hyaloid Artery;
Anomalies of the Lids ; Blastomyeosis ; Removal of
Speeial Foreign Bodies in the Eye ; the X-ray ; the
Newer Local Anesthetics and Preparations of the Supra-
renal Body ; Dionin ; Operations for Ptosis ; Pterygium,
Extirpation of the Lacrimal Sac, Extended Tenotomy,
Magnet Extraction ; Myasthenia Gravis, and in general
the applications of the newer additions to the Materia
Medica.
The best publications by which to become acquainted
with ophthalmic literature have largely changed since
the first edition of this book. This has made necessary
a complete re-writing of the bibliography of the subject,
and for general reference it is more convenient to bring
the whole bibliography together. This has been done
on pages 585-594. It is hoped that this work will still
merit favor, as one especially adapted for the systematic
reading of the student and the special reference book of
the general practitioner.
DENVER, COLORADO,
January, 1907.
PREFACE.
THIS book is intended to meet the needs of the general
practitioner of medicine and the beginner in ophthal-
mology. It is designed to aid in the actual work of deal-
ing with disease, and therefore gives the place of first
importance to the recognition and management of the
conditions likely to be presented early in practice, rather
than to the rarer diseases and more difficult operations
that may come later.
For practitioners in other departments of medicine and
surgery the most important phase of ophthalmology is
that of the relations of ocular symptoms and lesions to
general diseases. While Chapter XX is specifically de-
voted to these relations, the references it contains will, it
is hoped, put the reader in touch with the important re-
lated facts to be found in all the preceding chapters.
For the matter here presented the writer acknowledges
his large indebtedness to a host of patient workers in
ophthalmic science and art, although the scope of this
book forbids any attempt to properly apportion their
credit.
The bibliography at the end of each chapter is not
intended to be complete. It is merely an attempt to
open a path for the student into the broader literature
of ophthalmology. The references composing it have
been selected, not on account of their historical or general
scientific importance, but because they were deemed most
widely accessible, and best opened up the general litera-
ture of the subject.
The student who desires to search the whole domain of
recent ophthalmic literature can find the titles, for the
6 PREFACE.
years of its publication, in the Index Medicns ; and brief
abstracts in the " Systematic Reports on the Progress of
Ophthalmology " in the Archives of Ophthalmology. Most
important communications are reproduced in abstract in
the Ophthalmic Review and the Annals of Ophthalmology.
The most complete review of the world's literature is
published in German, in NageFs Jahresbericht ueber die
Leistungen und Fortschritte im Gebiete der Ophthalmologie.
For the relations of eye diseases to general diseases,
Schmidt-Rimpler's Erkrankungen des Auges im Zusam-
menhang mil Andern Krankheiten is the most complete
treatise, and furnishes the best bibliographies.
The following general treatises and papers of especial
value, but not belonging to any particular chapter, may
here be referred to :
American Textbook of Diseases of the Eye, Ear, Nose,
and Throat, edited by G. E. de Schweinitz and B. A.
Randall (referred to in chapter bibliographies as " Amer-
ican Text-book ").
System of Diseases of the Eye, edited by W. F. Norris
and C. A. Oliver (referred to in bibliographies as " Sys-
tem of Diseases of Eye ").
Text-book of Ophthalmology, by E. Fuchs, translated
by A. Duane.
Diseases of the Eye, by Geo. A. Berry.
The Origin of Inflammation, by Th. Leber. Abstracted
by Priestley Smith, " Ophthalmic Review," Nov., 1891, to
Feb., 1892.
The Pathological Examination of the Eyeball. C. D.
Marshall, " Royal London Ophthalmic Hospital Reports,"
vol. xiv. Part II.
Method of Mounting Ophthalmic Specimens. Priestley
Smith, "Ophthalmic Review," Jan., 1897.
DENVER, COLORADO,
CONTENTS.
CHAPTER I.
PAGE
Examination of the Patient; Case Records; Abbrevia-
tions 17
THE STUDY OF THE CASE, 17 — Case History, 17 — Inspection of
the Eyes, 17 — Family History, 18 — Special Examination, 18 — Ap-
proximate or Provisional Diagnosis, 19 — Case Records, 20—
Sketches and Diagrams, 21 — Field of Vision, 23 — Abbreviations,
23.
CHAPTER II.
Acuteness of Vision; Field of Vision; Subjective Phe=
nomena ; Color Blindness 25
ACUTENESS OP VISION, 25 — Test-objects, 26 — Five minute angle,
27 — Cards of Test-letters, 28 — Illumination, 29— Fingers, 29 —
Other Tests, 29 — Light Sense, 30 — IMPAIRMENT OF VISION, 30 —
Pin-hole Disk, 31 — Loss of Sight in One Eye, 32 — THE FIELD OF
VISION, 33 — The Perimeter, 34 — Taking the Field of Vision with
the Hand, 36 — Hernianopsia, 36 — Sector-like Defects of the Field
of Vision, 38 — Scotoma, 39 — Narrowing of the Field of Vision, 41
— Inconstant Impairment of Vision, 41 — Temporary Hemianopsia,
42 — Inconstant Narrowing of the Field of Vision, 42 — Muscse Voli-
tantes, 42 — Shadows of Retinal Vessels, 53— Circulation of Blood
in Retinal Vessels, 43 — SUBJECTIVE VISUAL SENSATIONS, 44—
Flashes of Light, 45— Visual Sensations of Ophthalmic Migraine,
45 — Distortion of a Point of Light, 45 — Rings of Light, 46 — Mul-
tiple Images, Diplopia, 46 — COLOR VISION, 47 — Color Fields, 47 —
Color Blindness, 48 — PAIN, 51 — Smarting and Burning, the Feel-
ing of a Foreign Body, 51 — Stinging, 52 — Aching, 52 — Neuralgic
Pain, 52 — fulness or Discomfort of the Eyes, 53 — Aching Outside
the Eyes, 53 — Headache, 53 — Loss of Sensibility to Touch, 54 —
Absence of Pain, 54.
CHAPTER III.
External Examination of the Eye ; Oblique Illumination ;
The Pupil 55
EXAMINATION OF THE LIDS, 54— Prominence of the Eyeball, 55
—The Lashes, 55 — Movements of the Lids, 56— Motility of the
8 CONTENTS.
PAOE
Eyeballs, 57 — Eversion of the Lids, 57 — HYPERKMIA, 60 — Lid-
margins, 60 — Hyperemia of the Conjunctiva, 60 — Pericorneal Red-
ness, 61 — Deep Hyperemia of the Sclera, 62 — Enlargement of tin-
Scleral Veins, 63 — Mixed Forms of Hyperemia, 63— S\\ 1:1,1,1x1,, r.:',
— Swelling of the Lids, 64 — Exophthalmos, 65 — Swelling of tbe"Con-
jnnctiva, 65— CONJUNCT! VAL DISCHARGE, 66 — Microscopic Exam-
ination, 67 — OBLIQUE OR FOCAL ILLUMINATION, 68 — The Magni-
fier, 68 — Opacities of the Cornea, 70— Reflections from the Surface
of the Cornea, 70 — Inspection of the Iris, 71 — THE PI»PIL, 71 —
Size of the Pupil, 72 — Pupillary Reactions, 72 — Reactions to Light,
73 — General Reactions of the Pupil, 75 — Transillumination, 77.
CHAPTER IV.
Ophthalmoscopic Diagnosis 78
THE OPHTHALMOSCOPE, 78 — Methods of Using the Ophthal-
moscope, 80 — OPACITIES IN THE MEDIA, 81 — EXAMINATION OF
THE EYE-GROUND, 84 — The Optic Disk, 84— The Retinal Vessels,
86— Color of the Fundus, 87— The Details of the Choroid, 87—
Region of the Macula, 88 — Retinal Reflections, 89 — NORMAL AP-
PEARANCES AND ANOMALIES OF THE RETINA, 90 — Haziness in
the Retina, 90 — Hemorrhage, 90 — Fatty Degeneration, 91 —
Medullated Nerve-fibers, 91 — Changes in the Retinal Vessels, 92 —
CHANGES IN THE OPTIC DISK, 93 — Redness, 93 — Opacity
of the Nerve-head, 94— Swelling of the Disk, 95— Pallor
of the Optic Disk, 96 — Cupping of the Disk, 97 — Anomalies of the
Optic Nerve, 98 — PIGMENTATION, 99 — Pigmentation of Optic
Nerve, 99 — Pigment-deposits in the General Fundus, 99 — Pigment-
deposits in the Retina, 99 — Choroidal Pigment-changes, 100 — Pig-
ment-blotches at the Macula, 101 — CHOROIDAL EXUDATE AND
CHOROIDAL ATROPHY, 101 — The Myopic Crescent, 102 — Other
Local Lesions, 102.
CHAPTER V.
Refraction ; Prisms and Lenses, and their Strength and
Numbering 103
REFRACTION OF LIGHT, 104 — Dioptric Media, -105— Index
of Refraction, 105 — PRISMS, 110 — Numbering of Prisms, 111 —
LKNSES, 112 — Varieties of Lenses, 114 — Strength of Lenses, 115 —
Numbering of Lenses, 116— The Trial Set, 119— Fogging, 121.
CHAPTER VI.
Refraction of the Eye ; Mydriatics and Myotics ; the Re-
fraction Ophthalmoscope ; Skiascopy 121
Assorting of Light, 121 — Refraction of the Eye, 123 — Accom-
modation, 124 — MYDRIATICS OR CYCLOPLEGICS AND MYOTICS,
127— Mydriatics, 127— Myotics, 129— OPTICAL THEORY OF THE
CONTENTS. 9
PAGE
OPHTHALMOSCOPE, 130 — DIRECT METHOD FOR THE MEASURE-
MENT OF REFRACTION, 131 — Emmetropia, 131 — Hyperopia, 131
— Myopia, 133 — SKIASCOPY, 134 — Myopia, 134 — Details of the
Test, 135 — Hyperopia, 139 — Emmetropia, 139 — Appearance of the
Light in the Pupil, 140 — Practical Applications of the Test, 141
—INDIRECT METHOD OF OPHTHALMOSCOPIC EXAMINATION, 142
— Special Methods, 143.
CHAPTER VII.
Errors of Refraction, Cylindrical Lenses, Presbyopia,
and the Wearing of Glasses 144
PRESBYOPIA, 144 — Symptoms, 144 — Diagnosis, 145 — Treatment,
145 — Prognosis, 147 — HYPEROPIA, 147 — Causes, 149 — Varieties,
149 — Symptoms, 150 — Diagnosis, 152 — Treatment, 153 — Prognosis,
154— MYOPIA, 155 — Causes and Course, 156 — Varieties, 158 —
Symptoms, 158 — Diagnosis, 162 — Treatment, 163 — Prognosis, 166
— ASTIGMATISM AND CYLINDRICAL LENSES, 167 — Cylindrical
Lens, 167 — Regular Astigmatism, 169 — Causes and Seat, 172 —
Varietes, 172— Symptoms, 173 — Diagnosis, 174 — The Ophthalmo-
meter, 178— Skiascopy, 180— Test-lenses, 183— Treatment, 184—
Prognosis, 186 — ABERRATION, 186 — IRREGULAR ASTIGMATISM,
187 — ANISOMETROPIA, 188 — The Mounting and Wearing of
Glasses, 189— Effects of Oblique Lenses, 190 — Periscopic Lenses,
190 — Changes with Age, 191.
CHAPTER VIII.
Disorders of the Ocular Movements 191
Ocular Movements, 192 — THE METER-ANGLE, 193 — PROJEC-
TION AND DIPLOPIA, 194 — Amblyopia with Squint, 198 — Causes
of Squint, 198— Diagnosis of Squint, 199— The Cover-test, 199—
Power of Moving Eyes in Different Directions, 200— Measuring
of Amount of Squint, 201 — Varieties of Squint, 203 — PARALYTIC
SQUINT, 204 — Causes, 204 — Varieties, 204— Symptoms, 205 — Diag-
nosis, 206 — Palsies of Particular Muscles, 208 — Treatment, 212 —
Prognosis, 214 — CONCOMITANT SQUINT, 215 — Causes, 215 — Varie-
ties, 216 — Convergent Squint, 217 — Divergent Squint, 218 — Ver-
tical Squint, 219— Diagnosis, 219— Treatment, 221— Prognosis, 224
— LATENT SQUINT, 225 — Varieties, 225 — Causes, 227— Symptoms,
227— Diagnosis, 227— Maddox Double Prism, 229— Systematic
Exercise, 233 — -Operations, 233 — Prognosis, 234— SPASTIC SQUINT,
234 — NYSTAGMUS, 234 — Nodding Spasm, 235 — Retraction of Eye-
ball, 235— Diseases of the Ocular Muscles, 236.
CHAPTER IX.
Diseases of the Conjunctiva 237
Hyperemia, 237 — Acute Catarrhal Conjunctivitis, 237— Exan-
thematous Conjunctivitis, 241 — Acute Contagions Conjunctivitis,
241— Diplobacillus Conjunctivitidis, 242— Ophthalmia Nodosa, 243
—Brief Recurring Episcleritis, 243— Purulent Conjunctivis, 243 —
10 CONTENTS.
PAGE
Croupous Conjunctivitis, 250 — Diphtheria of the Conjunctiva, 250
— Chronic Membranous Conjunctivitis, 253 — Chronic Catarrhal
Conjunctivitis, 253 — Parinaud's Conjunctivitis, 255 — Vernal Con
junctivitis, 255 — Follicular Conjunctivitis, 256 — Trachoma, 250 —
Petrifying Conjunctivitis, 261— Phlyctenular Conjunctivitis, 261 —
Pterygium, 265 — Pinguecula, 267 — Pemphigus, 267 — Xerosis, 268
— Tuberculosis and Lupus of the Conjunctiva, 268 — Syphilis of the
Conjunctiva, 268 — Amyloid Degeneration, 269 — Symblepharon,
269 — Edema, 270 — Emphysema, 270 — Ecchymosis, 270 — Tumors,
271 — Concretions, 271 — Bums, 272 — Discoloration, 273— Dist-asfs
of the Caruncle, 273.
CHAPTEK X.
Diseases of the Cornea and Sclera 273
General Conditions Regarding the Cornea, 273 — CORNEAL UL-
CERS, 276— Simple Ulcer of the Cornea, 276 — Suppurating Ulcer,
278 — Special Forms of Corneal Ulcer, 286 — Phlyctenular Keratitis,
288 — Abscess of the Cornea, Hypopyon, and Onyx, 290 — NON-
ULCERATIVE KERATITIS, 292 — Interstitial Keratitis, 292 — Punc-
tate Keratitis, 297— Striate Keratitis, 298— Pannus, 298— CORNEAL
OPACITIES, 300 — Causes and Varieties, 300 — Symptoms, 303 —
Treatment, 303 — PROTRUSIONS OP THE CORNEA, 305 — Anterior
Staphyloma, 305— Keratectasia, 309 — Conical Cornea, 309 — Kera-
toglobus, 310 — Tumors, 311— Burns of the Cornea, 311— DISKASKS
OF THE SCLERA, 311 — Scleritis, 311— Staphyloma of the Sclera,
313— Buphthalmos, 313— Injuries, 313.
CHAPTER XI.
Diseases of the Iris, Ciliary Body, and Choroid ; Sympa-
thetic Ophthalmia 313
UVEITIS, 314— IRITIS AND CYCLITIS, 314 — Iritis, 314 — Cyclitis,
324 — SEQUELS OF IRITIS AND CYCLITIS, 326— Myopia, 326 — Pos-
terior Synechiip, 326— Occlusion of the Pupil, 327 — Exclusion of
the Pupil, 327— Total Posterior Synechise, 328 — Atrophy and De-
generation of the Iris, 329— NEW GROWTHS IN THE IRIS AND CIL-
IARY BODY, 330— Gumma of the Iris and Ciliary Body, 330 —
Tuberculosis of the Iris, 330— Sarcoma of the Iris or Ciliary Body,
331 — Carcinoma, 331 — Benign Tumors, 331 — MOTOR DISORDERS
OF THE IRIS AND CILIARY MUSCLE, 332 — Myosis, 332— Cyclo-
plegia, 332— Spasm of the Ciliary Muscle, 333 — SYMPATHETIC
OPHTHALMIA, 333 — Sympathetic Inflammation, 334 — Sympathetic
Irritation, 340 — DISEASES OF THE CHOROID, 341 — Purulent Cho-
roiditis, 341 — Plastic Inflammation and Atrophy of the Choroid,
344 — Choroidal Hemorrhage, 349 — Detachment of the Choroid,
349— Colloid Masses, 349— Ossification of the Choroid, 349—
Shrinking of the Eyeball, 350 — TUMORS OF THE CHOROID, 350 —
Sarcoma, 350 — Carcinoma and Adenoma, 353 — ANOMALIES OF
CONTENTS. 11
PAGE
THE IRIS AND CHOROID, 353 — Anomalies of the Iris, 353 — Anom-
alies of the Pupil, 353 — Coloboma of the Choroid, 355 — Albinism,
355 — Minor Anomalies of Pigmentation, 356.
CHAPTER XII.
Diseases of the Retina 357
General Considerations, 357— Symptoms of Retinal Disease, 357 —
RETINITIS, 362— Simple Retinitis,. 362— Purulent Retinitis, 362—
Leukemic Retinitis or Neuroretinitis, 363— Hemorrhagic Retinitis,
364 — Albuminuric Retinitis, 365 — Gouty Retinitis, 368 — Diabetic
Retinitis, 368 — Syphilitic Retinitis and Chorioretinitis, 369 — Punc-
tate Retinitis, 370— Striate Retinitis,. 370— Proliferating Retinitis,
371 — Circinate Retinitis, 371 — Retinitis from Excessive Light, 371
— Pigmentary Degeneration, 372 — Amaurotic Family Idiocy, 374 —
Angioid Streaks in the Retina, 374 — Retinal Macular Atrophy, 374
— Spasm of the Retinal Arteries, 374 — Obstruction of the Retinal
Vessels, 374 — Thrombosis of the Retinal Artery, 376— Thrombosis
of the Retinal Veins, 377— Detachment of the Retina, 377— Sub-
retinal Cysticercus, 380 — Glioma of the Retina, 380 — Anomalies
of the Retina, 381.
CHAPTER XIII.
Diseases of the Optic Nerve, Visual Tract and Centers ;
Amblyopias 383
Hyperemia of the Optic Nerve-head, 383 — Anemia of the Optic
Disk, 384 — INFLAMMATIONS OF THE OPTIC NERVE, 384 — Neuro-
retinitis, 384 — Optic Neuritis, 385 — Retrobulbar Optic Neuritis,
391 — ATROPHY OF THE OPTIC NERVE, 391 — Optic Nerve Atrophy,
391 — OTHER ORGANIC CHANGES IN THE OPTIC NERVE, 396 —
Hyaline Bodies in the Nerve-head, 396 — Tumors of the Optic
Nerve, 396 — Coloboma of the Optic Nerve, 397 — Toxic AMBLY-
OPIAS, 397 — Tobacco Amblyopia, 397 — Alcohol Amblyopia, 399 —
lodoform Amblyopia, 400 — Bisulphid of Carbon Amblyopia, 400
— Nitrobenzol Amblyopia, 400 — Quinin Amblyopia, 401 — Salicylic
Acid, 402— Acetanilid, 402— Jamaica Ginger. 402— Filix Mas, 402
— CONGENITAL, HYSTERICAL, AND SIMULATED AMBLYOPIAS, 402
— Congenital Amblyopia, 403- — Amblyopia from Imperfect Focus-
sing, 403 — Congenital Color Blindness, 403 — Hysterical Amblyopia
and Simulated Amblyopia, 403 — Developmental Alexia, 406.
CHAPTER XIV.
Diseases of the Anterior Chamber, Crystalline Lens and
Vitreous Humor 407
THE ANTERIOR CHAMBER, 407 — Depth, 407 — Alterations of the
Aqueous Humor, 407 — Hyphemia, 408 — Infection, Obstruction,
Cysts, 408 — DISEASES OF THE CRYSTALLINE LENS, 408 — Cataract,
408 — Alterations of the Lens by Age, 408 — Senile Cataract, 409 —
Juvenile or Soft Cataract, 418— Partial Cataract, 419 — Anterior
12 CONTENTS.
PAGE
Polar Cataract, 419 — Posterior Polar Cataract. 420 — Lamellar
Cataract, 420 — Fusiform and Central Cataract, 421 — Secondary
Cataract, 421— Dislocation of the Lens, 424 — Coloboma of the
Lens, 425 — Lenticonns, 426 — Aphakia, 426 — DISEASES OF THE
VITREOUS, 426 — Vitreous Opacities, 426 — Fluid Vitreous, 428 —
Hyalitis, 429 — Hemorrhage into the Vitreous, 429 — Blood-vessels
in the Vitreous, 430 — Detachment of the Vitreous, 430 — Par-
asites in the Vitreous, 430— Persistent Hyaloid Artery, 431.
CHAPTER XV.
Disorders of Tension of the Eyeball 432
Normal Intra-ocular Currents and Pressure, 432 — Testing of
Intra-ocular Tension, 434 — GLAUCOMA, 434 — Primary Glaucoma,
435 — Glaucoma with Exacerbations, 435 — Simple Glaucoma, 443 —
Secondary Glaucoma, 444.
CHAPTER XVI.
Diseases of the Libs, Lacrimal Apparatus, Orbit, and
Orbital Walls 448
ANOMALIES OF THE LIDS, 448 — INFLAMMATION OF THE LIDS,
448 — Blepharitis, 448 — Blastomycosis, 448 — Marginal Blepharitis,
449 — Stye, 450 — Abscess, 450 — Tarsitis, 450 — DISEASES OF THE
SKIN OF THE LIDS, 451 — Eczema, 451 — Fissures of the External
Canthus, 451 — Toxic Dermatitis, 451 — Erysipelas, 45? — Herpes
Zoster, 452 — Molluscum, 452 — Warts and Horn-like Growths, 453
— Xanthelasma, 453 — Milium, 453 — Spontaneous Gangrene, 453 —
Syphilis, 453 — DISEASES OF THE LASHES AND EYEBROWS, 454—
Pediculosis, 454 — Trichiasis ; Distichiasis, 454— DISTORTIONS, DIS-
PLACEMENTS, AND ADHESIONS OF THE LIDS, 455 — Entropion, 455
— Ectropion, 456 — Lagophthalmus, 456 — Blepharospasm, 457 — Pto-
sis, 457 — Epicanthus, 458 — Blepharophimosis, 458 — Anchylobleph-
aron, 458— SWELLINGS AND TUMORS OF THE EYELIDS, 459 —
Edema, 459 — Emphysema, 459— Chalazion, 459 — Liponia, 400 —
Fibroma, 460— Neuroma, 460— Cysticercus, 460 — Angioma, 460—
Sarcoma, 461— Lupus, 461 — Epithelioma, 461— Burns, 462 — DIS-
EASES OF THE LACRIMAL PASSAGES, 462 — Epiphora, 462 — Closure
of the Punctuin, 463 — Displacement of the Punctum, 464 — Obstruc-
tion of the Canaliculus, 464— Obstruction of the Nasal Duct, 4(15
— Lacrimal Abscess, 467 — DISEASES OF THE LACRIMAL GLAND,
467 — Inflammation, 467— Hypertrophy, 468 — Dislocation, 468 —
Cyst, 468— Tumors, 468— DISEASI-S OF" THE ORBIT" AND ORBITAL
WALLS, 468— Orbital Cellulitis, 468— Inflammation of the Oculo-
orbital Fascia, 470 — Periostitis, Caries, and Necrosis, 470 — Enoph-
thalmos, 471 — Exophthalmic Goiter, 472 — Pulsating Exophthal-
mos, 472 — Angiomala, 474 — Dermoid Cysts of the Orbit, 474 —
Other Cysts, 475 — Orbital Tumors, 475 — Imperfect Development,
476— DISEASES OF THE ADJOINING CAVITIES, 476— Maxill:n-y An-
trmn, 476— Frontal Sinus, 477 — Ethmoidal Sinus, 478 — Sphenoidal
Sinus, 478.
CONTENTS. 13
CHAPTER XVII.
PAGE
Mechanical Injuries of the Eye and its Appendages . . . 479
CONTUSIONS, 479 — Bruise of the Eyelids, 479 — Fracture of the
Bones of the Orbit, 479 — Dislocation of the Eyeball, 480— Rupture
of the Eyeball, 480— Contusion of the Eyeball, 481— Rupture of
the Iris, 481 — Paralysis of the Iris Sphincter, 481 — Traumatic Cy-
cloplegia, 481 — Hemorrhage into the Vitreous, 482 — Injuries of
the Lens, 482 — Traumatic Edema of the Retina, 483 — Injuries of
the Choroid, 483 — WOUNDS WITHOUT LODGEMENT OF FOREIGN
BODIES, 485 — Wounds of the Lids, 485 — Penetrating Wounds of
the Orbit, 486 — Wounds of the Conjunctiva, 487 — WTounds of the
Cornea, 487 — Wounds of the Sclera, 488 — Wounds of the Ciliary
Body, 488 — Wounds Involving the Iris, 488 — Wounds of the Lens,
489— Wounds Involving the Vitreous, 491— FOREIGN BODIES IN
THE EYE AND ORBIT, 491 — Lids and Orbit, 492 — Foreign Bodies
in the Conjunctiva, 492 — Foreign Bodies in the Cornea, 493 —
Foreign Bodies in the Sclera, 495 — Anterior Chamber and Iris,
495 — Lens, 496 — Vitreous, Retina, and Choroid, 496.
CHAPTER XVIII.
Remedies and their Applications 500
RONTGEN RAYS, 500 — REST, 500 — MASSAGE, 501 — APPLICA-
TIONS OF HEAT AND COLD, 502 — THE MAKING OF APPLICATIONS
TO THE CONJUNCTIVA, 504 — ANTISEPTIC AND CLEANSING SOLU-
TIONS, 507— COXJUNCTIVAL APPLICATIONS, 509 — DUSTING POW-
DERS, 511— CAUSTICS, ASTRINGENTS, AND IRRITANTS, 511 — OINT-
MENTS, 513— ANESTHETICS, 514 — MYDHIATICS, 516 — CYCLOPLE-
GICS, 517 — MYOTICS, 519— MISCELLANEOUS SOLUTIONS, 520 —
DRUGS USED FOR THEIR SYSTEMIC INFLUENCE, 520.
CHAPTER XIX.
Common Ophthalmic Operations 523
GENERAL CONSIDERATIONS, 523 — Preparation of Patient, 523
— Preparation of Surgeon, 524 — Preparation of the Instruments,
524— Position and Illumination, 525 — Retraction of the Lids and
Fixation of the Eyeball, 525 — Sponging, 527 — DRESSINGS, 527 —
HEMOSTASIS, 529 — ABSTRACTION OF BLOOD, 529 — OPERATIONS
UPON THE LIDS, 529 — Removal of Displaced Lashes, 529— Entro-
pion and Distichiasis, 531 — Canthotomy, 532 — Canthoplasty, 532 —
Division of the Upper Lid, 533 — Union of the Lids, 533 — Ec-tro-
pion Operations, 534 — Plastic Operations on the Lids, 525 — Epi-
thelial Grafts, 535 — Ptosis Operations, 536— Chalazion, 537—
OPERATIONS ON THE CONJUNCTIVA, 537 — Pterygium, 537— Sym-
blepharon, 538 — Epithelial Grafts, 538 — Trachoma Operations,
539— Peritomy, 539 — OPERATIONS ON THE LACRIMAI, PASSAGES,
540 — Syringing, 540 — Slitting the Canaliculus. 540 — Probing the
Nasal Duct, 541 — Lacrimal Stricture, 542 — Extirpation of Lacri-
14 CONTENTS.
PAGE
mal Sac, 542 — OPERATIONS ON THE EYE-MUSCLES, 543 — Teno-
toiny, 543 — Advancement, 544 — OPERATIONS ON THE CORNEA,
545 — Removal of Foreign Bodies, 545 — Curetting of the Cornea,
546— Paracentesis, 546 — Incision of Corneal Ulcer, 546 — Actual
Cautery, 547 — Galvano-cautery, 547 —Tattooing the Cornea, 548 —
Excision of Anterior Staphyloma, 548 — OPERATIONS ON THE
SCLERA, 549 — Anterior Sclerotomy, 549 — Posterior Sclerotomy,
549 — OPERATIONS ON THE IRIS, 549 — Iridectomy, 549 — Iridotomy,
552 — Corelysis, 552 — Iridencleisis, 553 — OPERATIONS ON THE LKNS
AND ITS CAPSULE, 553 — Simple Extraction, 553 — Extraction with
Iridectomy, 557 — Linear Extraction, 557 — Suction-operation, 557
— Extraction within the Capsule, 557 — Scoop-extraction, 557 —
Wenzel's extraction, 557 — Discission, 558 — Capsulotomy, 559 —
Removal of Lens for High Myopia, 560 — OPERATIONS ON THE
EYEBALL, 560 — Magnet-extraction, 560 — Enucleation of the Eye,
561 — Evisceration, 564 — Implantation of an Artificial Vitreous, 565
Paraffin Spheres, 565 — Osteoplastic Resection of Orbital Wall, 566.
CHAPTER XX.
Ocular Symptoms and Lesions Connected with General
Disease. ... .566
DISEASES OF THE NERVOUS SYSTEM, 567— SYMPTOMS OFTEN EX-
PLAINED BY OCULAR EXAMINATIONS, 568— DISEASES OF THE CIR-
CULATORY SYSTEM AND KIDNEYS, 572 — DIATHETIC DISEASES, 574
— CHRONIC INFECTIOUS DISEASES, 575 — ACUTE INFECTIOUS DIS-
EASES, 577 — CONDITIONS OF THE SEXUAL ORGANS, 581 — DISEASES
OF THE NOSE, 582 — POISONS, 583.
Bibliography
DISEASES OF THE EYE.
CHAPTER I.
EXAMINATION OF THE PATIENT; CASE RECORDS;
ABBREVIATIONS.
THE STUDY OF THE CASE.
THE study of a case should begin with an attentive
hearing of the case history, noting especially the symp-
toms to which chief importance is attached or from
which relief is sought. This takes time, but it is time
well spent. It is the more important because in most
ophthalmic cases the diagnosis rests chiefly on what the
surgeon discovers by special methods of examination ; and
on that account the patient's view of his case is liable to
be neglected altogether. An attentive hearing strengthens
the patient's confidence. Even the time occupied by a
garrulous patient in utterly insignificant details need
not be wasted.
The patient being seated facing the surgeon, in a good
light, the careful inspection of the eyes and face can go
on with the case history. The attitude of the head may
indicate weakness in certain ocular muscles ; a constant
frown may suggest eye-strain ; unconscious movements
to avoid the light tell of photophobia. The ocular move-
ments are to be noted, and the appearance and positions
of the lids and the lashes. The brightness of the corneal
surface, the presence or absence of hyperemia of the globe,
the evidence of conjunctival discharge, the existence and
extent of scars on the eyeball, lids, lacrimal apparatus, or
related parts, should claim attention. The color and
reaction of the iris, and the form, size, and color of the
pupil give evidence regarding intra-ocular conditions.
The case history is to be extended in all important
2 17
18 EXAMINATION OF THE PATIENT.
directions by questions, especially as to headache, nervous
symptoms, and previous attacks of eye disease or general
illness. The patient's age is so often an important ele-
ment in the case that it should always be ascertained.
Family history is chiefly of value as to the occurrence
of blindness and the age at which it occurred ; although
in connection with optic neuritis, or ocular affections due
to general disease, it may be important in other directions.
Consanguinity of parents is sometimes important ;, and
race and previous place of residence may throw light on
some cases. With women the facts as to menstruation
and child-bearing should be brought out.
The personal or family history of syphilis is so often of
primary importance that it should always be in the sur-
geon's mind. The direct question as to previous syphilis
is mostly worthless as to family history, and often yields
nothing as to the history of the patient. It may be
sometimes omitted. But the careful inquiry for evidence
of syphilitic lesions should never be neglected.
The special examination of a case should generally
begin with tests of the acuteness of vision, with the test-
type at four or six meters. If the vision is good enough
to make near vision of small objects possible, the near
point of distinct vision should be ascertained. The bal-
ance of the ocular muscles may be tested with the
Maddox rod. Next, the anterior segment of the eye
should be carefully inspected by the oblique illumination,
first with the unaided eye and then through a magnifying
lens, noting the transparency of the cornea and crystalline
lens, the smoothness of the corneal surface, the depth of
the anterior chamber, and the appearance of the pupil and
the iris.
The most important step in the routine examination, to
be applied to all cases in which it is possible, is the
ophthalmoscopic examination. This should include the
inspection from a distance to ascertain the transparency
of the media and the general color of the fundus reflex,
the measurement, more or less careful, of the refraction of
the retina or other points to which attention is directed,
THE STUDY OF THE CASE. 19
and finally the careful inspection of the details of different
parts of the eye-ground.
Such a routine examination will furnish the material
for an approximate or provisional diagnosis, and
indicate the direction for further investigation. For
instance, if there is reason to suspect lacrimal disease, the
puncta and region of the lacrimal passages must be
minutely studied. Pressure is to be made over the
lacrimal sac to try if there be any accumulation within
it. If there are indications of conjunctival disease, the
lid will be everted and the conjunctiva examined. In
either of these cases the discharge may be studied micro-
scopically and bacteriologically, and the nose should be
carefully examined for causative or related lesions.
If there has arisen reason to suspect disorders affecting
the ocular tension, this should be tried, after the ophthal-
moscopic examination, by the method detailed in Chapter
XV. The tension should be tested in all obscure cases.
If ametropia be an important factor in the case, the
ophthalmoscopic examination should be supplemented
by skiascopy, the ophthalmometer may be used, and the
refraction should be tested with trial-lenses, and if need-
ful, a mydriatic employed.
If the earlier examination has pointed to disease of
the optic nerve or central nervous system, or to lesions of
the retina, the field of vision is to be taken, first for form
and then for certain colors, green, red, and blue ; and the
condition of the reflexes and other evidences of the state
of the general nervous system are to be investigated.
Should the routine examination, especially that of the
fundus, reveal evidence of general disease, such as
Bright's disease, diabetes, severe anemia, syphilis, tuber-
culosis, etc., the special examination must include the
search for other evidences regarding such conditions.
Certain examinations as to the general conditions, as the
testing of the urine for albumin and sugar, should be
made as a matter of routine before undertaking important
operations, such as extraction of cataract. Justice to the
patient requires a constant lookout for general manifesta-
20 APPROXIMATE DIAGNOSIS.
tions of constitutional diseases that may have affected the
eye, as syphilis, rheumatism, gout, or tuberculosis.
It may be stated as a general principle that disease of
a tissue represented in the eye, especially if chronic,
should raise the inquiry as to the condition of similar
tissues in the other organs. Disease of the skin of the
lids should lead to the inquiry as to skin disease in other
parts of the body. Conjunctivitis should make the sur-
geon consider the condition of other mucous membranes.
Disease of the retinal vessels strongly suggests vascular
disease elsewhere throughout the body, as optic-nerve
disease suggests disease in other parts of the nervous
system.
Case Records. — The keeping of accurate case his-
tories soon teaches the unreliability of one's recollections
of symptoms. Jn ophthalmic practice the need for case
records is the greater because of the wide variations that
occur in different normal eyes. An appearance that must
be regarded as of no serious import in the optic disk of
one patient might be significant of grave organic disease
when observed in the eye of another. It is often of great
importance to know if a certain lesion be recent or of
long standing ; and some lesions, such as an opacity in the
cornea, lens, or vitreous, or an atrophy or disturbed pig-
mentation of the choroid, may exist unchanged for many
years, presenting such an appearance that it is impossible
to judge from it the age, and therefore the significance,
of the lesion. To know of the previous existence or
non-existence of such conditions, and to know the pre-
vious vision and muscular balance of the eyes, is often
essential to a correct prognosis or a full understanding of
the case.
"What to record is a serious question for young sur-
geons ; later a species of selection occurs, each learning
for himself to select the facts to be especially noted. It
wastes time and tends to befog important points with
irrelevant detail to attempt to make each case record
encyclopedic, but there are certain things which it is wise
to note in every case.
CASE RECORDS. 21
The record should show the name, sex, and age of the
patient ; and race and nativity may have considerable
scientific value. The patient's address is important in a
business way and for the identification of the case. The
occupation should be reported, so as to show the actual
character of the daily work ; thus, " house work, sews
three hours a day ;" " teacher, French and German,
written exercises." Every note made should be dated.
The vision of each eye should be noted, with any
circumstance especially atfecting it, as the use of a cor-
recting lens and its strength, the name of the mydriatic
employed, its strength, and the time since its instillation.
If at succeeding visits vision is found unchanged, no note
regarding it is required. But whenever a change in the
acuteness of vision occurs, it should be recorded.
The notes should include the clearness or lack of clear-
ness in the dioptric media, and the general condition of
the eye-ground. All decided anomalies and scars due to
former injury or disease should be noted, so that at a
subsequent date any marked departure from the normal,
not mentioned in the record, may be presumed to have
occurred since the case was last examined. Such a pre-
sumption may, however, prove misleading, unless great
care is taken in the examination of every case, and the
complete record is made at the time.
The record will include such points of personal and
family history as are deemed important. Generally it is
useless to record a negative, unless the negative is itself
of great significance, as the absence of albumin from the
urine in a case of apparent albuminuric retinitis. Besides
the chief clinical features of the case, and all treatment
instituted, it is often well to record also the prognosis or
the definite opinion given. It is very embarrassing to
have a former opinion quoted, often incorrectly, against
one's self, with no recollection of the real facts to correct
misapprehensions.
Sketches and diagrams of anomalous or morbid
appearances are an extremely valuable part of case
records. They abbreviate by replacing verbal descriptions,
22 SKETCHES AND DIAGRAMS.
and often give a more complete and exact record than any
verbal description can. To facilitate their use, case books
have been prepared with outline diagrams of the lids, the
anterior segment of the eye, and the fundns ; also stamps
by which such outlines can be reproduced. These are
sometimes helpful, but not essential. For recording
fundus lesions a plane ground of the fundus color, which
can be rubbed or scraped away to white, and will readily
take black and other colors, is most helpful. The
essential thing is practice and familiarity with the making
of such sketches. A large part of the skill is in the
seeing of the thing to be sketched ; and no one can be
regarded as well trained in ophthalmology who cannot
make such sketches as will be valuable additions to his
case records.
In working in»black and white, the lead-pencil is more
manageable than pen and ink ; but additional effects can
be secured by using both. For making water-color or oil
sketches, some little acquaintance with the laying and
combination of colors is required, but not more knowledge
of color values than is needed to appreciate the various
appearances presented by the fundus of the eye.
By judicious selection of points to be noted, by use of
abbreviations, including those to be mentioned below, and
the employment of sketches, when needed, a very good
case history may be recorded in the space commonly
occupied by two or three hundred words of manuscript.
Such histories may be written in an ordinary blank-book,
one or two cases to a page ; and, if well indexed, this is
quite satisfactory for the ordinary purposes of private
practice.
For the comparative study of similar cases, for the
division of clinical work among several workers, and for
hospital records, a card record is superior. This may
be kept on specially prepared blanks in a special form of
case, or on ordinary Manila cards kept in a box. The
card record has the advantages that it can be written with
the typewriter and that the individual card may be small,
while for cases with prolonged histories any number of
CASE RECORDS. 23
cards may be used. Arrangement in alphabetical order
renders the ordinary index unnecessary ; but indexes may
be added, giving references and cross-references to all
desired classes of cases.
The careful study of a case presenting any marked
defect of the field of vision will usually include the
mapping of the field. The map or diagram is preserved
by fastening it to the other part of the case record, or in
a " field book," with a reference to the record. A very
useful record of the field of vision can, however, be made
in this way :
60 55 80
60 R. 95
65 75 90
Normal field for form for the right eye. The letter in the center tells
which eye, and the figures the number of degrees the field extends in the
different directions.
Abbreviations allow the condensation of a case so
that it will occupy less space, and may be more quickly
looked over. Those given below are in general use or
have proven of special service to the writer. Some of
them arc used throughout this book. Such abbreviations
are puzzling when different authors use similar abbrevia-
tions to indicate entirely different meanings. Snellen
used D. to indicate the distance at which a letter of any
given size would subtend the angle of five minutes ; while
D. has come to be universally understood as meaning
diopters. Nettleship used O. I), for optic disk, although
it is very generally used to mean oculus dexter, the right
eye.
Abbreviations :
A. or Ace., Accommodation.
As., Astigmatism, or astigmatic.
Ax., . Axis of cylindrical lens.
Base of prism.
C. or Cyl., Cylinder, or cylindrical lens.
Cm., Centimeter.
Or. . Centrads.
IX Diopter, or diopters.
Emmetropia, or emmetropic.
H. Hyperopia, or hyperopic.
24 A BBRE VIA TIONS.
HI. or H. L. Hyperopia latent.
Hm. or H. M. Hyperopia manifest.
M. Myopia, or myopic.
M. a. Meter angles.
mm., Millimeters.
Pp., Punctum proximum, near point of dis-
tinct vision.
Pr. , Presbyopia.
B. or B. E. or O. D., The right eye.
L. or L. E. or O. S., The left eye.
S. or Sph., Spherical lens.
~T~. Intraocular tension ; +Ti increased
tension ; — ~|~, diminished ten-
sion. (See Chap. XV.)
V. Vision, or acuteness of vision.
Obi., Results of examination by oblique
illumination.
Oph., Results of ophthalmoscopic examina-
tion.
Skia., Results of skiascopic examination.
Mom., Results of examination with ophthal-
mometer.
-f- Plus, or convex.
Minus, or concave.
Combined with.
Degrees.
In making records of the balance, or lack of balance
of the ocular muscles — records that must be made many
times and compared, to be of much service — the following
are found useful :
Orth., Orthophoria, or proper balance in all
directions.
— Proper lateral balance.
< or Ex., Exophoria, less than normal conver-
gence, tendency to divergence.
> or ESQ., Esophoria, more than normal tendency
to convergence.
|| Vertical balance.
V Bt. Hyperph. Right hyperphoria, tendency of the
right eye to turn above the left.
/\ Lt. Hyperph. Left hyperphoria, or tendency of the
left eye to turn above the right.
ACUTENESS OF VISION. 25
CHAPTER II.
ACUTENESS OF VISION ; FIELD OF VISION ; SUBJEC-
TIVE PHENOMENA; COLOR-BLINDNESS.
ACUTENESS OF VISION.
NORMAL vision requires focussing of light upon the
retina, and the transmission of the nervous impulses
caused by the focussed light, through the optic nerve and
tract, to the normally related centers in the brain. Dis-
turbance of any part of this series of actions causes impair-
ment of the vision. The character of the impairment often
indicates the seat of the disturbance.
Acuteness of vision is tested, as the acuteness of touch,
by the ability to recognize the separateness of impressions.
If two points of light make upon the retina impres-
sions sufficiently removed from one another, they appear
as separate points ; but if the impressions be brought
closer and closer together, there comes a limit in the
power to distinguish between them, the two fuse into one,
and the eye sees but a single point of light.
The distance the impressions must be separated in
order to appear separate might be measured upon the
retina. In Fig. 1, this would be the distance between a
and 6, the point on which impressions are made by rays
from A and B.
FIG. 1.— The visual angle.
It is better to indicate their separation by an angle
formed by these rays, A a and B b. These rays cross
at a certain point, called the nodal point of the eye (N),
26 THE VISUAL ANGLE.
and at that point make an angle ANJ3, and its equal t Ill-
angle aNb (Fig. 1).
By testing many persons, it has been found that the
angle between the direction of the two rays that will give
separate impressions in a normal eye is about one minute,
one-sixtieth of a degree. In some healthy eyes it is
slightly greater than this. In others with especially good
sight, the angle is notably less, but most eyes fairly con-
form to the standard of a one-minute angle as the normal
acuteness of vision.
To ascertain the acuteness of vision of an eye,
we test its visual angle. This might be done by taking
two points at a certain distance and bringing them
closer together until they appeared as one, and noting the
smallest angle at which they could be seen as separated.
For convenient, it is better to have a series of points
separated by varying distances, and find out which of
these can be distinguished at a certain known distance
from the eye.
Test Objects. — The simplest test object is a group
of black dots on a white card. The person tested is
required to tell the number of dots in each group. A
series of such groups, graduated so as to be distinguished
at different distances, makes a test for visual acuteness
which is applicable to the illiterate and to persons of all
nationalities (Fig. 2).
: •: x :: n c a u
FIG. 2.— Dots large enough to be FIG. 3. — Incomplete square test for
counted at five meters. full vision at six meters.
Another test, which has the same range of application,
is that proposed by the writer, in which the figure of an
incomplete squai-e is used and the deficient side turned
either up or down or to the right or left, as shown here
(Fig. 3).
The patient is required to designate which side is
ACUTENESS OF VISION. 27
incomplete, and thus to show at what distance the separate
arms are distinct from one another. With normal acute-
ness of vision, the space between the arms subtends an
angle of one minute, the whole figure subtending an
angle of three minutes.
The most generally popular and valuable tests, how-
ever, are carefully arranged series of test letters.
Snellen, who first put test types on a scientific basis,
arranged series of letters, each of which should have five
spaces in height and five spaces in width, that must be
seen in order that the letter should be distinctly recog-
nized. As each part of the letter must make its dis-
tinct impression on the retina, the size chosen was such
that the whole letter. should subtend an angle of five
minutes, at the distance at which it was to be seen by an
eye with normal acuteness of vision. This is illustrated
by the block letters E and B of Fig. 4, which should
be recognized at a distance of ten meters.
FIG. 4.— Snellen letters which subtend an angle of five minutes when placed
at ten meters.
To recognize fully each portion of such a letter
requires about the five-minute angle that Snellen fixed
upon. There are, however, many letters in the alphabet,
as O, L, T, and others, which can be recognized without
seeing distinctly five separate parts of height or breadth.
Hence, for many persons with normal vision, most of
the letters of the Snellen scale are too large ; and patients
frequently recognize at twenty feet letters intended to be
seen at ten or fifteen feet. On many test cards, B and S
are the only letters requiring full normal vision for their
recognition at the given distance.
This has led to the employment of smaller letters, such
28 TEST LETTERS.
as would subtend an angle of four or four and one-half
minutes at the required distance. But with any test card
different letters of uniform size will be seen at different
distances or with different degrees of distinctness. This
makes the apparent acuteness of the vision depend some-
what upon the particular card employed.
The great practical advance made by Snellen was in
numbering his test type by the distance at which they
could be read by a normal eye. He thus enabled the
surgeon to make definite records of the acuteness of
vision suited for comparison. * Such records are made by
expressing the acuteness of vision by a fraction, of which
the denominator is the distance at which the letters should
be visible, and the numerator is the greatest distance at
which they can be read. Thus, if letters which should
be visible at forty feet can only just be read at twenty
feet, the acuterlfess of vision is expressed by the fraction
|^. This distance may be expressed in terms of any
unit, as feet, meters, or inches. If the six- meter type
be read at four meters, the vision will be recorded as
^, or if the thirty-inch type is just made out at eighteen
inches, the record will be ^fths. Snellen used Roman
numerals for the denominators, in-tending thus always to
indicate the number of feet at which the type should
be read. Thus ~ indicated vision normal at twenty
feet.
The cards Of test letters as commonly printed have
each line marked with the number of feet or meters, or
both, at which it should be visible to the normal eye.
Any test card intended for use at a certain distance
should have at least one row of letters upon it smaller
than can be read by eyes with normal acuteness of vision
at that distance, to provide for cases in which the vision
is above the standard.
Test letters are used by placing the patient at the
distance corresponding to a line of letters upon the test
card, commonly four or six meters (fifteen to twenty feet).
He is then requested to read all the letters he can at this
standard distance. When it is impossible to read even
ACUTENESS OF VISION. 29
the largest letter on the test card at the standard distance,
the vision is to be tested by bringing the card nearer until
the largest letter is made out. The distance at which
this is done will then be the numerator for the fraction,
the distance at which the letter should be read being the
denominator.
In all use of test letters, great care should be taken
to secure a good and uniform illumination. Any
deficiency or variability in the brightness of the illumi-
nation will vitiate the results of such tests. The card
can be exposed to the light from an area of unobstructed
sky. This will be sufficient during the brighter portions
of fair days. But to secure constant illumination, it is
better to employ artificial light, which should be as bright
as that of a good Argand burner, placed within twelve
inches of the card.
Counting- Fingers. — When it is impossible to read even
the largest letters at a distance of a foot, the acuteness
of vision is to be tested by holding up the fingers against
a dark background and requiring the patient to count
them. The ability to do this is recorded as " counts
fingers " at a distance of so many inches. The ability to
count fingers at a certain distance, requires slightly less
power of vision than the reading of the sixty meters or
two hundred feet letters at the same distance.
Other Tests. — When fingers cannot be counted, even a
very few inches from the eyes the power of vision is to be
tested by moving the hand in different directions and re-
quiring the patient to indicate in what direction it is moved.
The ability to do this will be recorded as " ability to see
moving objects."
When objects cannot be seen, the eye should be tested in a
darkened room as to its ability to recognize the direction of
a lamp-flame, "light-projection," and when a lamp-flame is
turned up or down, or brought closer or carried farther
away from the eye, the power of " quantitative perception
of light." Where these are lacking, the test is to be made
of concentrating a bright light upon the eye, and then turn-
ing it away, and leaving the eye in complete darkness, and
30 TESTS OF LIGHT-PERCEPTION.
requiring the patient to say when the light is thrown on
the eyes and when it is removed. This tests the po\v<-r
of simple " light-perception." In applying the test for
light-perception in one eye, care must be taken to have
the other thoroughly covered with some opaque object ;
simply closing the lids does not answer, because light-
perception is quite possible through the closed lids of a
sound eye. The power of vision is to be tested for each
eye separately. (See page 32.)
The accurate determination of the power of vision
frequently requires special care, not to be misled by state-
ments of the patient. In the reading of test letters, the
patient will frequently stop as soon as the recognition of
the letters requires effort, and say that he can see no more.
Yet, by taking a little more time, and coaxing the patient
to guess at on* letter after another, he can be made to
read a line or two farther down. Mistakes indicate the
approach to the limit of visual acuteness. Patients often
believe they can see considerable light, although quite
blind. They must be required to tell the number of
fingers held up, the direction the hand is moved before
the face, or when the light is made brighter or dimmer.
I/ight Sense. — The amount of light necessary to ren-
der visible the test area in a dark chamber is called the
light minimum. The smallest difference of illumination
perceptible when two unequally lighted areas are com-
pared is the light difference. These are tested by a special
apparatus, a photometer, which consists essentially of a dark
chamber in which test areas are illuminated through an
adjustable aperture by a standard candle, or equivalent
source of light. Test letters seen under diminished
illumination, or against various gray backgrounds, also
test the light sense.
IMPAIRMENT OF VISION.
Vision better than £ or ;° of the Snellen scale, as f or
if' mav generally be regarded as normal. Vision that
falls below this should be regarded as impaired, and the
cause of impairment should be sought for.
IMPAIRMENT OF VISION. 31
In seeking the cause of impairment of vision, we must
first inquire, Is vision impaired for all distances, and at
all times? Impairment of vision for objects at one dis-
tance, when objects at another distance can be seen
perfectly, can only depend upon imperfect adjustment of
the eyes for the distance at which the vision is impaired.
This imperfect adjustment may be due to abnormality of
the muscles that turn the eyes, but generally it is due to
imperfect focussing.
If a patient can only read the thirty-meter type at four
meters, but can read the quarter-meter type at one-fourth
of a meter, the focussing for four meters is imperfect, the
impairment of vision is due to myopia. If, on the other
hand, distant objects are always seen more clearly, but
there come times when the patient is unable to read fine
print or do fine sewing at the ordinary working distance,
this fact alone demonstrates that the power of accom-
modation, the power of focussing the eyes for near work,
is insufficient for the continuous demand made upon it.
If impairment of vision exists for all distances, but
greater at one distance than another, the difference is due
to imperfect focussing.
If the impairment of vision be equal for all distances,
it may still be due to imperfect focussing. This can be
determined by using the pin-hole disk of the trial set,
or, making a pin-hole in cardboard, and holding it
before the eye. Looking through such a minute opening,
the vision is always improved if its defect is due to
imperfect focussing, which can thus be differentiated from
impaired vision due to any other cause.
When the impairment of vision affects objects equally
at all distances, but is inconstant, it usually depends
on some serious derangement of the nervous apparatus of
vision, the optic nerves, tracts, or centers. When the
impairment is constant, and looking through the pin-hole
does not improve it, it probably depends upon organic
changes, which may be either within the eyeball, where
they will be visible ; or in the deeper structures where,
perhaps, no other direct evidence of their existence may
be obtained.
32 IMPAIRMENT OF VISION.
I/OSS of Sight in One Eye. — In testing the power
of vision, each eye is to be tested separately, care being
taken to effectually cover the other eye without making
any pressure upon it. Pressure on the eyeball diminishes
the power of sight for the time ; and having subjected
one eye to pressure while testing the other, we should
not get its full acuteness of vision upon testing it. It is
better to hold something in front of the eye to be ex-
cluded, than to permit the patient to hold it closed while
he looks with the other. The act of holding one eye
closed while the other is open, often requires excessive
pressure of the lids of the closed eye.
Impairment of vision affecting only one eye arises from
disease in front of the optic chiasm, in the optic nerve or
the eye itself. Fig. 5 illustrates
the course of the nerve fibers
and the connections of the nerve
centers concerned in the act of
vision. The fibers coming from
the retina of one eye pass back
through the optic nerve until
they reach the chiasm, and there
separate into two sets that do
not again come together. Those
from the temporal half of the
retina are associated with fibers
from the nasal half of the retina of the other eye ; and those
from the nasal half of the retina are associated with fibers
from the temporal half of the retina of the other eye. Hence,
any lesion interrupting them back of the chiasm will pro-
duce impairment of the vision in both eyes, and not
interference of one alone. Gowers, however, believes
that in each half of the cerebral cortex there is a higher
center concerned only with the eye of the opposite side,
and that disturbance of this center causes a crossed blind-
ness of one eye. Cases of that kind rarely, if ever, reach
the ophthalmologist.
THE FIELD OF VISION.
THE FIELD OF VISION.
33
The form of the normal field of vision is shown in
Fig. 6. R. is a diagram of the field for the right eye
as commonly represented. The cross at the center
marks the direction in which the eye is looking, the point
210
'330
PIG. 6.— Chart of field of vision of right eye. The center of the circles repre-
sents the fixation point, and the small shaded area to the right of it the physi-
ological blind spot.
upon which it is fixed. The small circle near it indicates
the physiological blind spot, corresponding to the entrance
of the optic nerve. The concentric circles indicate each
ten degrees of departure from the visual axis.
To the temporal side, and a little downward, the field
extends beyond ninety degrees from the visual axis. In
other directions it is somewhat limited by the brow, nose,
and cheek, making the normal field unsymmetrical for
each eye alone, but symmetrical as to the median line,
when the fields of both eyes are viewed together. The
two fields overlapping have a certain portion, common to
both, in which alone binocular vision is possible. This
is shown in Fig. 7, where the two fields are super-
34 THE NORMAL FIELD.
imposed, the cross representing the direction of fixation
for both eyes.
The Perimeter. — The field of vision may be accur-
ately mapped out by lise of a perimeter, shown in
Fig. 8. This consists essentially of an arc that can be
revolved about an axis passing through its center, broad
enough and blackened to furnish a background for the
test object. The patient's eye is placed at the center of
this arc, the chin rest and cheek rest being designed to
keep it fixed in this position. The visual axis is turned
FIG. 7. — Fields of vision for the two eyes superimposed. White area the field
of binocular vision. The cross marks the point of fixation, and the circles on
either side the physiological blind spots of the respective fields.
in the direction of the axis of the instrument B by fixing
the gaze on a point in that direction.
To use the perimeter the arc is set in a certain
direction, and a test object is moved along the arc, and
the limit determined at which it becomes invisible. The
position of the. arc is then changed and the trial is
repeated. This is done until a sufficient number of points
have been determined to indicate the outline of the field.
The test object mostly employed is a white square one
centimeter on the side. If another is used it should
be especially noted.
A better method for accurately determining hemian-
opsia. is to fix the test object upon the arc a certain
number of degrees from its axis ; then to revolve the arc
THE FIELD OF VISION.
35
the test object describing a circle, and the patient noting
where on this circle it appears and disappears.
The blackboard is used to take the field of vision by
having the patient fix a mark in the center, and moving a
piece of chalk to and from this mark. A line joining the
parts at which the chalk appears or disappears gives the
FIG. 8.— Registering perimeter.
outline of the field. The blackboard method is chiefly
serviceable for central portions of the visual field. A
modification of it, Bjerrum's method, is used for the accu-
rate study of slight defects in this region. Instead of the
blackboard a 2-meter square of jet black cloth is placed
2 meters from the eye. Before this the test objects, which
36 VSE OF THE PERIMETER.
are. usually 1 or 2 mm., but may vary to 20 mm. square,
are moved by a black rod.
Taking the field of vision with the hand will
usually be found most convenient and sufficiently accu-
rate in practical work. To do this, the patient is
seated facing the surgeon, so that the light shall fall
equally on both. If the right eye is to be tested, the
patient closes his left, and the surgeon his right eye,
and each looks directly at the open eye of the other.
AVhile the eyes are thus directed, the surgeon carries his
hand to one part of the periphery of the field of vision.
He brings the hand towards the visual axis in a plane
half way between himself and the patient until the fingers
are just perceptible to himself. Then moving the fingers
or holding them still, he requires the patient to say which
he is doing. rJJJiis is repeated at all parts of the boundary
of the field of vision. If the field be normal, the patient
answers correctly whenever the position of the fingers
is clear to the surgeon. If the field be limited in some
one direction, the patient in that direction will require
the hand to be brought closer to the visual axis to recog-
nize these movements.
In making this test, the surgeon superimposes the
visual field of one of his eyes upon the visual field of the
eye he is testing. A corresponding allowance must, of
course, be made for difference in height of nose, or promi-
nence of brow, or cheek ; and, at best, the test is only to
be regarded as an approximate one. But it is one that is
easily made anywhere, and it will reveal the presence of
any such condition as hemianopsia.
Hemianopsia, or half blindness, is the condition
where objects are seen with distinctness in one-half of the
field of vision, while in the other half there is partial or
complete blindness. In hemianopsia, the blind half of
the visual field is commonly separated from the seeing
half by a vertical line. When the right half of the field
is blind (the left half of the retina), it is called right
hemianopsia; when the left half is blind (the right
THE FIELD OF VISION. 37
half of the retina), it is called left hemianopsia. If
the right half of the field for each eye is blind (temporal
field for right eye, nasal field for left eye), it is called
right homonymous hemianopsia. Where the left
half of each field is blind (nasal field of right eye, and
temporal field of left eye), it is left homonytnous
hemianopsia.
Fig. 9 represents the field of vision in a case of right
homonymous hemianopsia.
Homonymous hemianopsia depends always on some
FIG. 9. — Field of vision in right homonymous hemianopsia, from apoplectic
lesion involving left occipital lobe.
lesion back of the optic chiasm. Reference to Fig. 5
will show that it is back of the chiasm that the nerve
fibers concerned with these portions of the visual fields
come together. Right hemianopsia indicates a lesion
back of the chiasm in the left optic tract, or in the cere-
brum. Left hemianopsia indicates a lesion of the right
tract, or cerebrum.
Occasionally, bitemporal hemianopsia occurs. In
this, the temporal half of each field (corresponding to the
nasal half of each retina) is blind, indicating that the fibers
which cross at the chiasm are injured, while the other
fibers have escaped. This locates the lesion definitely at
the optic chiasm. The other forms described are :
Binasal hemianopsia, which might be due to sym-
metrical pressure on both tracts just opposite the chiasm,
the crossing fibers escaping ; and altitudinal hem-
ianopsia, the loss of the upper or lower half of the
field of vision. The last, if not due to detachment of
the retina, or other lesion within the eye, may generally
38 HEMIANOPSIA.
be regarded as a symptom of hysteria, or as one of the
hysterical symptoms, which occur in connection with
organic disease of the brain, but it might be due to a
disease of a limited portion of the visual centers.
In homonymous hemianopsia, the line dividing the
blind from the seeing portions of the field of vision is
not always vertical. Its apparent inclination to the right
or left may be due to an incorrect position of the head
and eyes while taking the field. But in most cases it
deviates towards the blind side near the fixation point,
passing some five degrees or more from it and leaving the
center of the field of vision unaffected. This seems to
indicate that the part of the retina corresponding to this
center of the field of vision, is supplied with fibers con-
necting it with both sides of the brain.
Hemianopsia »may involve color-perception alone, so
that one-half of the field of vision is simply color-blind,
hemichromatopsia ; or it may amount only to a loss
of ability to recognize form as clearly in one-half of the
field of vision as in the other. These varieties are called
relative hemiauopsia.
Hemianopsia from organic disease is usually permanent,
and is absolute, light-perception being lost in the affected
part of the field. But transient relative hemiauopsia is
not rare. In hemianopsia, the reaction of the pupil to
light thrown upon the blind portions of the retina should
always be tested. Its significance is given with the
reactions of the pupils (Chapter III).
Sector-like defects of the field of vision are
essentially like hemianopsia, except that less of the field
is lost. They are broad at the margin of the field with
an angle towards the center, but generally leaving cen-
tral vision unaffected. When one-quarter of the field is
lost, it is called a quadrant defect. Such a defect may
be relative or absolute. It may be due to disease or
pressure acting only on certain portions of the optic tract,
or radiating fibers; or may arise from disease of part
of the visual cortex.
THE FIELD OF VISION. 39
Fig. 10 represents the appearance of the field in such
a case.
Such a defect should be sought for when sudden
obscure interference with vision is complained of. The
patient does not usually understand the nature of his
FIG. 10.— Sector defect of the field of vision from gunshot wound involving the
left occipital lobe.
trouble ; and, unless the visual field is tested, the exist-
ence of such defect will escape observation.
Scotoma. — A scotoma is an area of partial or com-
plete blindness lying within the field of vision. The
patient may notice it as a cloud obscuring vision in a
certain direction, positive SCOtoma due to disease of
the retina ; or merely as a space in which objects are not
seen, negative SCOtoma due to conditions of the optic
nerve, tract, or centers. The physiological blind spot is
an example of the latter variety.
A scotoma may be either relative or absolute — that is,
vision in the part of the retina corresponding to it may
be impaired, or entirely lost. Scotomas^ may affect any
part of the field of vision. Generally they occur in a
single eye, or, when present in both, depend on separate
lesions, even when symmetrically placed. They com-
monly depend on lesions in the eyes themselves, or of the
optic nerve in front of the chiasm. True SCOtoma,
due to a lesion of the retina or optic nerve, is fixed in
position. It is to be distinguished from false SCOtoma,
and the obscuration of vision that may arise from an
opacity, a small blood-clot, or connective-tissue formation,
floating in the vitreous. A false scotoma changes its
position with reference to the axis of vision, upon
40
SCOTOMA.
movement of the eye. It is positive scotoma that is
liable to be confused with the shadow thrown by an
opacity in the vitreous.
A form of special importance is central SCOtoma due
to disease of the choroid and retina in the region of the
macula, to toxic amblyopia, or to a special form of retro-
bulbar neuritis. Central scotoma presents special diffi-
culties in the determination of its boundaries, because the
impairment of vision involving the fixation point pre-
vents the patient from keeping his eye continually turned
in a certain direction throughout the test. It is best
mapped out by having the eye directed at first to a series
of concentric circles upon the black-board or a sheet of
paper. The large circles must be seen outside of the
region of the scotoma, enabling the
patient to keep the eye compara-
tively fixed. It is to be noted at
what points the inner circles are
obscured. These points being con-
nected by lines give a map of the
scotoma. This map may be revised
by having the patient fix his eye
upon it, and notice whether as it is
moved from him the outline drawn
disappears within the scotoma all
at once. By repeated revisions, an
accurate diagram of the scotoma is
thus obtained. Figure 11 represents such a diagram.
Instead of concentric rings we may use a group of dots.
The patient sees these by a flash of light, and tells how
many are seen and their position (Hess). Binocular fixa-
tion may be used where but one eye is affected. The
patient fixes with the sound eye through some form of
stereoscope, the defective eye being directed by a diagram
similar to that presented to the sound eye (Haitz).
Central color scotoma is detected by holding test wools
of several colors behind a sheet of paper with an opening
of 1 to 10 mm. which the patient fixes. The patient is
required to name the colors successively shown behind
Fi«. 11.— Diagram of cen-
tral scotoma from tobacco
amblyopia, the actual size
of the absolute scotoma at
one meter.
THE FIELD OF VISION. 41
the opening. If the patient be allowed to look away from
the opening, so that the impression is made upon some
portion of the retina other than that affected (the macula),
the color might be correctly named, although at the fixa-
tion point the color blindness were complete.
Ring SCOtoma is a form in which the center of the
field of vision and the periphery remain normal, or less
impaired than a ring-like area surrounding the center of
the field. It may possibly be due to a lesion affecting a
special portion of the optic nerves or tracts, but generally
it is caused by disease in the corresponding portions of
the choroid and retina. Most frequently, scotomas are
single, or arranged without symmetry ;.they may be per-
manent or quite transient. The latter will be referred to
in connection with transient impairment of vision.
Narrowing of the field of vision is the most
significant symptom of atrophy of the optic nerve and
certain allied affections. It is ascertained by testing
the field of vision with the hand or with a perimeter.
Symmetrical narrowing points to primary atrophy of
the optic nerve or to the effects of certain poisons.
[See Quinin Blindness, Chapter XIII.] It is apt
to affect the field of vision for colors before there is any
notable change in the field for form. Irregular nar-
rowing of the field, which may also affect the field for
colors more than the field for form, is indicative of second-
ary optic atrophy, or injury to the tracts as by glaucoma,
optic neuritis, etc.
Inconstant impairment of vision after the eyes
have for some time been used for close work, occurring
particularly in the latter part of the day, or when the
eyes are used by artificial light in the evening, is caused
by the sudden relaxation of the accommodation, after the
ciliary muscle has been exerted until it is tired and will
work no longer. It is apt to occur in persons coming to
the age when they require glasses for near work, or in
young persons who have high hyperopia. It may occur
in such persons for a short time after eating a meal.
42 INCONSTANT IMPAIRMENT.
Sudden brief blurring of the sight of one eye may be
caused by pressure on the eyeball.
What is often spoken of as a blurring of the sight of
one eye, is temporary hemianopsia, a blurring of one
half of the field of vision, or a sector-like defect. It may
be accompanied with the appearance of irregular figures
and rays of light. This symptom is due to some dis-
turbance of the visual tracts or visual centers. It com-
monly lasts for a few minutes, and, as it disappears, is
followed by a severe headache, which may be confined to
one part, or may spread all over the head. Frequently
the whole of the field of vision is involved in such an
obscuration. The attacks occur at irregular intervals,
sometimes quite frequently, for years.
Temporary SCOtomas may be caused by the exhaus-
tion of the retina from gazing so that a bright light will
fall continuously on some one part of it. Such a scotoma
is noticed after looking at the sun, or" an electric light.
It usually occupies the center of the field of vision, inter-
fering with the perception of the object looked at ; biit it
may appear in some other part of the field. When the
object gazed at has decided color, the scotoma may have
the complementary color. In certain conditions of the
retina these scotomas may be made to change color by
changes in the general illumination of the retina, or by
pressure on the eyeball.
Inconstant narrowing of the field of vision,
particularly diminution of the field while being tested,
is indicative of hysteria or neurasthenia.
Muscse volitantes (named from their apparent simi-
larity to flying flies) are shadows cast upon the retina
by specks in the vitreous humor. Such shadows are
chiefly noticed by myopic eyes. But something of the
kind may be brought out in any eye by entoptic observa
"tion ; that is, by looking through a small pin-hole held
one-half inch before the eye with a uniformly illuminated
background, or by looking through a microscope with the
field illuminated but unoccupied by any distinguishable
object. Such shadows move with the specks causing them,
THE FIELD OF VISION. 43
when the eyes move ; but do not preserve a constant
relation to the visual axis or the point looked at. When
the eye ceases to move they do not at once come to rest,
but gradually settle up or down across the field of vision,
until they reach the position of rest. The smaller and
more delicate of these shadows have generally the shape
of dots which may be arranged in strings, or of threads.
The larger ones may assume any shape. The patient
often becomes familiar with the shape of each and can
promptly recognize it. The depth of such specks may
be measured by using two pin-holes about half the width
of the pupil apart. With these two overlapping lumin-
ous circles are seen, and in the overlapping portion the
shadows are seen double. The distance between the
double images is to the distance between the centers of
the two circles, as is the distance of the speck in front
of the retina, to the distance of the pupil in front of the
retina, about 18 rrim.
The shadows of the retinal vessels may be rendered
visible in the dark room by sitting in the position
for oblique illumination of the eye, turning the eye
strongly toward the nose, concentrating the light on the
sclera with a convex lens, and then moving the lens
slightly up and down, or back and forth. This shows
the shadows of the larger trunks of the retinal vessels,
except those that pass to the nasal side, the so-called
figure of Purkinje.
The figure of the finer vessels which ramify in the
region of the macula may be brought out by looking at a
uniformly illuminated background through a pin-hole held
close to the eye and moved rather rapidly in a small circle
before the pupil. The movement must be kept up for a
minute or so, and then a figure like that of Fig. 12 slowly
makes its appearance.
The circulation of the blood in the retinal vessels
may be seen by looking at a uniform light cloud, or at
the sky, through a rather dark-blue glass. Looking
steadily* two or three minutes, small light oval bodies will
appear, moving rapidly toward the center of the field,
44 RETINAL CIRCULATION.
but before reaching it turning and whirling away again.
These are corpuscles moving in the capillaries, sometimes
retarded and elongated in narrow portions, then regaining
their form and gliding rapidly onward. They are seen to
follow definite paths, but the walls of the vessels through
which they pass are invisible. For certain intelligent
FIG. 12.— Arrangement of minute vessels at center of macula.
patients, it is possible to use the entoptic method, figures
of the retinal vessels, and the retinal circulation to study
minute intraocular lesions. Minute specks of the vitreous
opacity may be studied entoptically, although not percep-
tible in any other way. Somewhat larger opacities after
being located in this way may be recognized with the
oph thai moscope .
SUBJECTIVE VISUAL SENSATIONS.
The removal of an eye or the complete blindness of
both eyes is not followed by a continual sense of dark-
ness; and, in the absence of the normal stimulus to the
visual centers, vision memories may be so vivid that it is
difficult to convince the patient that he does not still see.
In some cases the sensations, particularly of flashes of
light, become quite annoying. They may indicate
SUBJECTIVE VISUAL SENSATIONS. 45
mechanical, circulatory, or reflex excitation of the visual
centers, possibly proceeding from the stump of the optic
nerve or some portion of the visual tract, but generally
from other sources.
Flashes of I<ight. — These may arise from excitation
of any part of the visual tract. The most common cause
acting within the eye and giving rise to them is the irrita-
tion or involvement of the retina, in connection with
acute choroidal inflammation. Where this is strictly
localized, flashes may appear confined to a single part of
the field of vision. Where the attendant hyperemia is
more general, the sensations will be more widely dis-
tributed. They are most evident in complete darkness
with the eyes closed, and, sometimes can be provoked at
will by pressure of the lids on the globe. Their liability
to be affected by pressure upon the eyeball is the means
of distinguishing flashes of light due to ocular disease
from those due to irritation of the nerve tracts or centers.
The abnormal visual sensations of ophthalmic
migraine are found by most patients difficult to describe,
yet the account given of them cannot be mistaken for
anything else. They are sometimes compared to the
quivering of the air over a heated surface ; sometimes to
the glimmer of light in the water ; at others to a stream
or flood of water, proceeding from a particular part of the
field of vision. Most frequently they are compared to
fire-works ; and a figure with re-entering angles like a
fortification is very often alluded to. In a few cases
they take definite recognizable forms, as that of a ball of
fire, or even a human face or outline figure. Generally
the appearances vary at different stages of the attack,
passing away as a cloud of luminous mist, which may be
the only appearance noticed. The feeling is, not that the
part of the field of vision is blind, but that the real
objects in it cannot be perceived through these subjective
visual appearances.
Distortion of a Point of I/ight. — The conventional
figure of a star, a central point surrounded by divergent
rays, is based upon the fact that a point of light present"
46 DISTORTION OF A POINT.
such an appearance to a great majority of eyes. This
arises from stigmatism ; mostly from irregular stigmatism.
An eye free from this defect sees a point of light simply
as a brilliant dot.
The exact figure presented differs for each eye, as is
demonstrated by comparing closely the position and the
length of the rays of the right and left eyes used sepa-
rately. It may also be made to vary by changes in
accommodation. Any change in such a figure indicates
a change in the stigmatism. This may be dependent
upon changes in the cornea, as by corneal ulcer or abra-
sion, or in the crystalline lens, as before cataract.
Rings of light exhibiting different colors of the rain-
bow about a point of light, as a lamp-flame, are usually a
symptom of glaucoma. They may, however, arise apart
from glaucoma*through alterations in the cornea.
Multiple Images; Diplopia. — Monocular Diplo-
pia. — When a single object gives rise to two or more
impressions, we must, by closing one eye, ascertain
whether this symptom exists when only one eye is used.
If the diplopia be monocular, it commonly depends on a
defect of the refracting surfaces, or media. It may
indicate a dislocation of the lens, so that part of the light
entering the eye passes through the edge of the crystalline
lens, while another part passes alongside of it. Similar
monocular diplopia is produced by looking through the
edge of a spectacle lens or prism. Or it may arise from
great inequalities in the lens itself, and from changes
preceding cataract, or from the prismatic action of facets
in the cornea; from either of these latter causes the
images noticed will be irregular and imperfect and will
generally be of unequal distinctness.
Irregularities of the dioptric apparatus sufficient to
cause multiple images can always be detected by careful
objective examination. Where no such irregularities
exist to account for monocular diplopia, it must be
regarded as due to abnormality of the visual centers. In
this form the images are commonly perfectly definite and
regular, although not always of equal intensity. This
COLOR VISION. 47
variety of diplopia is probably in most cases only pre-
tended. It may occur in hysteria, or as one of the
hysteroid symptoms of organic disease of the brain. Its
reality is very difficult to determine.
Binocular Diplopia. — Double vision, the one image
belonging to one eye, and the other to the other eye,
always indicates that the eyes are not both turned in the
same direction, but that they squint. The subject is
therefore considered mainly in connection with paralyses
of the ocular muscles and squint. (See Chapter VIII.)
But while such diplopia cannot exist Avithout squint,
the squint may be present without diplopia. Although
the eyes may be turned in different directions, one may
not perceive any image of the object looked at, or the
image may be so feeble as to be disregarded. In some
cases the second image may be noticed at times and at other
times be absent ; and this may mean either that the squint
is temporarily absent, or that the second image is for the
time unnoticed. The diplopia is apt to be persistent and
annoying where squint has occurred during adult life, if
vision remains good in the squinting eye.
COLOR VISION.
None of the theories of color perception, explained
in works on physiology, is fully established. They
are of much theoretic interest, but have not sufficient
bearing on ordinary clinical ophthalmology to justify
repetition here.
Color perception is a more delicate function of the
nervous apparatus of vision than the perception of form,
and is more easily impaired or destroyed by disease.
Color perception is most vivid at the center of the
macula, from which point the retina becomes less sensitive,
most rapidly for green, almost as rapidly for red, and
more slowly for blue.
In general shape, the color fields resemble the field
for form. With the usual one-centimeter square of color
for a test object, the fields are about as shown in
48
COLOR BLINDNESS.
Fig. 13. Narrowing of the field is to be ascertained
with colored tests, as impaired field for form is studied
with a white test object. Hemichromatopsia and color
scotoma have been referred to on pages 38 and 40.
The appearance of objects as to color is largely a
matter of contrast. Colored vision is a curious phenom-
enon, probably due to contrast. Blue vision, kyanopsia, is
usually seen after the extraction of senile cataract. The
FIG. 13.— Fields of vision for colors of the right eye. The dotted line shows
field for green, the alternate dots and lines that for red, and the broken line
for blue. The solid line is the field for form.
cataract has long given an amber or brown tinge to
all the light entering the eye through it ; and when it is
removed the light seems to have the complementary color,
blue. If the other eye is still the seat of cataract, and
therefore continues to receive the amber light, the con-
trast may keep the blue color noticeable for several weeks.
But if the other eye receives uncolored light, the blue
quickly fades away.
Red vision, or erythropsia, is noticed sometimes after
cataract extraction or after exhausting disease, but more
frequently after prolonged exposure of the eyes to bril-
liant illumination, as in high mountain regions and upon
the Polar snow-fields.
Color Blindness. — Narrowing of the color fields
may extend to their complete extinguishment. This is
COLOR VISION. 49
seen in connection with severe diseases of the retina,
optic nerves, or visual centers, and constitutes a variety
of color blindness.
More frequently color blindness is a congenital defect
which becomes apparent when the attempt is made to
discriminate certain colors. In the great mass of cases the
colors imperfectly perceived are red and green, this form of
defect being known as red-green blindness. Cases occur
in which the complementary colors, orange and blue, or
yellow and purple, are not recognized, but these varieties
of color blindness are very rare.
Something of the effect of color blindness may be pro-
duced by viewing objects through colored glasses. The
objects still seem to have color, but not their proper
colors, and the change is most noticeable with regard
to the color of the glass used or its complementary
color.
Congenital color blindness cannot be cured or overcome
by any course of training. Its recognition is of impor-
tance in connection with certain occupations. Inability to
recognize red or green may be extremely dangerous in a
pilot or railway engineer. But on the other hand, persons
who have imperfect perception of color learn to distin-
guish objects by their shading, and often excel in work
devoid of color but requiring the exact appreciation of
shading, as in engraving, or judging of black goods.
For practical purposes, the defect is to be recognized
by the Holmgren test with colored wools. . For this the per-
son to be tested is given certain skeins of colored wools
called test-skeins, and required to select from a pile of
miscellaneous colors, the skeins which most nearly match
the test. The skeins from which the selection is to be
made include some of the same color as the test, but of
lighter or darker shades. These are called- "match
skeins." With them are mixed skeins of what are
known as " confusion colors," colors which appear to the
normal eye entirely different from that of the test skein,
yet are most likely to be selected by the color blind as
resembling it. The first test is one of very light green,
50 THE HOLMGREN TEST.
to be matched with skeins of the same hue ; and such
skeins the normal-sighted will select without hesitation.
The color blind will, however, place with this a sage
green, red, very light brown, or gray. With these may
also be placed some of the match skeins. Or the person
tested, while not actually placing the confusion colors
with the test, may pick them up and consider them as
closely resembling it. Some of the confusion skeins, as
the sage green, indicate an imperfect perception of color
short of complete color blindness.
The first test is to detect the existence of color blind-
ness of any kind. A second test shows whether it is red
blindness, or green blindness. This test skein is of light
pink, and should be matched by darker skeins of rose
pink. But the red blind will incline to place with it
dark blue or purple, while the green blind will choose the
confusion colors, dark gray or green. A third test skein,
used in confirmation of the results obtained with the
others, is a bright red. In red blindness it will be
confused with dark greens or browns. In green blindness
it will be confused with lighter greens or browns.
Complete color blindness is rare, but incomplete color
blindness is quite common. Among males about 4 or
5 per cent, fail to match accurately the test skeins,
but among females only one-half of 1 per cent, make
similar mistakes.
For positions in which colored signals have to be used
and obeyed, nothing less than perfect color perception is
admissible, because even those whose color perception is
but slightly below the normal, will err in quick decisions
as to signals seen through fog, snow, or smoke, or when
in rapid motion.
Other methods to test the power to recognize colors are :
the placing of colored squares or colored letters upon a
black background and determining the distance at which
the colors can be recognized. Or, in imitation of the
signals in ordinary use, a lamp-flame at a considerable
distance from ' the eye may be covered successively by
glass of different colors. Or letters of red and green may
PAIN. 51
be placed on a gray background, where by a color-blind
eye either the red or the green will not be noticed.
These latter tests are of practical value principally in
detecting small central color scotoma, and for confirm-
ing the results of the tests with colored wools ; or
in demonstrating, to those not familiar with color blind-
ness, the justice of decisions based on the wool tests.
PAIN.
Pain, although a symptom to which attention is pretty
certain to be called by the patient, is one about which it
is often difficult to get a clear and accurate impression.
As to its severity the manifestations of suffering on the
part of the patient are but an imperfect guide. One
patient makes little complaint of pain that has entirely
prevented sleep, while another manifests great excitement
over pain of very moderate severity. Then too, the same
morbid process, running in other respects the same course,
will in one case cause severe pain and in another very
little. So that the symptom cannot be regarded as indi-
cating the severity of the disease causing it, as compared
with similar attacks in other persons. Even in a given
case it is liable to vary without close relation to the prog-
ress of the disease, although generally its marked abate-
ment may be taken as a positive sign of improvement.
Different persons describing pain of the same kind
differ greatly in the terms they employ, and a consider-
able acquaintance with such descriptions is necessary
to their proper appreciation. In any case it is well to
try to get the patient to describe his pain in more than
one phrase.
Smarting and Burning; The Feeling of a
Foreign Body. — Pain described as of this kind, may
be usually regarded as due to conjunctivitis. Sometimes
the patient will only characterize it as the feeling of
"something in the eye." It is liable to vary greatly in
severity. It is aggravated by dust, exposure to air, light,
or heat, or by the use or movement of the eyes.
52 SMARTING AND BURNING.
If due to an acute conjunctivitis it will be accompanied
with noticeable hyperemia of the conjunctiva. But if it
arises from chronic inflammation the conjunctiva may
appear paler than normal.
Such pain, usually slight but sometimes severe, may
follow the use of cocain even in the normal eye, being
noticed from one to four hours after the use of the drug.
It may also be produced by the use of atropin or one of
the other mydriatics, in patients who have an idiosyncracy
toward these drugs. A common exciting cause is eye-
strain, particularly beginning presbyopia in persons who
are trying to continue to work without glasses. In such
cases, there is usually hyperemia at the time the pain is
felt, but this may not be noticed, and only the pain com-
plained of. Such pain may also be due to a foreign body
in the cornea oi*conjunctival sac, or to the misplacement
of an eye-lash.
Stinging is a term which may be used to describe the
same sensation as is frequently called smarting or burning,
and will then have the same significance. Or, it may be
used to indicate a totally different form of pain, a sudden
lancinating pain due to cramp of the ciliary muscle, or
neuralgic in character.
Aching may be a sort of extreme spontaneous sore-
ness, as in inflammatory disease with swelling and tension
of sensitive parts ; or it may be a nerve pain of the same
character as headache, sometimes described as " a head-
ache in the eyes." The inflammatory ache may be spoken
of as burning, especially where there is conjunctival or
corneal disease present. Its significance is mainly as evi-
dence of severe tension of the parts from inflammatory
exudate. It may be severe in corneal disease, but is
more apt to be severe in iritis or cyclitis or glaucoma.
Aching of the eyes, independent of inflammation, most
frequently arises from eye-strain ; but sometimes through
choroidal congestion, and sometimes through cramp or lire
of the ciliary muscle.
Neuralgic Pain. — This may be described as shoot-
ing, aching, or burning, and may be a manifestation of
PAIN. 53
either functional or organic nerve disease. In cases of
ophthalmic zoster, or other serious disease of the ophthal-
mic branch of the fifth nerve, it is liable to be extremely
severe and persistent ; and, in such cases it requires care
to discriminate between pain having such an origin, and
that which might be attributed to the inflammatory con-
ditions usually present in such cases.
Fulness or Discomfort of the Byes. — Many cases
of eye-strain present more or less constantly this symptom
or sensation, only occasionally rising into an actual head-
ache.
Aching Outside of the Bye. — It is frequently
stated by the patient that the eyes are free from pain,
but that there is aching or pain back of them. This fre-
quently means that the pain is really in the eyeball ; and
not upon its surface or in the lids ; that it has a different
location from that produced from something getting into
the eye.
But, in some cases it seems fair to refer such pain to
the region of the orbital muscles or their attachments.
Any severe pain affecting the eyeball is likely to be
referred to adjoining parts. Thus in glaucoma or iritis,
the pain may be complained of as situated mainly in the
brow or cheek. In such cases, however, the history
generally shows that it started in the eye and then spread
to the adjoining parts.
Headache. — It ought to be universally recognized
that eye-strain is the common cause of headache. Aside
from headaches produced by fever, toxemia, and organic
disease of the brain and its membranes, eye-strain is
almost invariably a factor in the production of headache.
The headache of eye-strain is not of any special char-
acter. It may be constant or intermittent ; slight or severe,
felt only on the use of the eyes, or felt after their use,
continuous, or recurring irregularly, or at certain intervals.
It is aggravated by many other causes, such as hunger,
exhaustion, exposure to heat or cold, or indigestion ; or it
may seem entirely independent of other influences. In the
majority of cases eye-strain is not the only factor in the
54 HEADACHE.
production of headache. But it may be the only factor
of practical importance because it alone can be removed,
and its removal will give relief. Such headaches arc
generally felt in the frontal, temporal, or occipital regions.
Rarely arc they most severe in the vertex.
I,O*SS Of sensibility to touch results from disease
of the centers, trunk, or peripheral branches of the fifth
nerve. It is often not noticed by the patient. It is dis-
covered by comparing the sensibility of one eye with that
of the other, as by touching one cornea and then the
other with a pledget of absorbent cotton rolled up to a
point. The extent of the reflex produced by the touch
of the cotton on the cornea is to be noted, as well as the
distinctness of sensation. Decided diminution in the
sensibility of the cornea is found in connection with
malarial neuralgia (brow ague), in herpes, where it may
coexist with intense pain, and in glaucoma.
Absence of pain is notable in some diseases where
it might be expected to be present. Thus, severe infl-mi-
mation of the optic nerve and retina, or plastic inflam-
mation of the choroid, may run its course without giving
rise to any pain whatever. Iritis is usually extremely
painful, but some cases are quite free from pain, until the
disease has existed for many days or weeks, and has caused
the firm adhesion of the iris to the lens over a large part
of the surface of contact. Cataract is quite painless, and
complaints of pain about the eyes should always suggest
in old persons the possibility of glaucoma. (See Chap. X V .')
CHAPTER III.
EXTERNAL EXAMINATION OF THE EYE; OBLIQUE
ILLUMINATION; THE PUPIL.
THE examination of the eye should begin by careful
inspection of the lids and neighboring parts in a good light
EXTERNAL EXAMINATION OF THE EYE. 55
— at first without touching the eyes or in any way inter-
fering with them. This inspection may begin with the
lids closed, afterward continuing with them open, and
should include careful comparison of the two sides of the
face. The lids may present some congenital deficiency
— coloboma of the lids — which may leave part of the
eyeball continuously exposed. If the lids be of normal
formation, inability to close them entirely will be due to
loss of power in the orbicularis muscle. This is liable
to arise from disease of the facial nerve. The portion
distributed to the orbicularis is frequently involved with
disease of the oculomotor nerve without the involvement
of other portions of the seventh or facial nerve.
Prominence of the Eyeball. — Pushing forward
of the eyeball causes separation of the lids, and sinking
of the eyeball in the orbit narrows the space between the
lids. Opening the eye widely causes an appearance of
protrusion, while narrowing of the palpebral fissure pro-
duces apparent sinking of the eyeball in the orbit. The
actual prominence of each eye should be carefully noted.
The prominence of the center of the cornea is measured
with the exophthalmometer. This is placed against the
outer margins of the two orbits, and gives the number of
mm. that the cornea advances in front of the line joining
these two points. The simplest form of the instrument,
the proptometer, consists of a flat scale hollowed out for
the prominence of the nose and eye. At either end are
millimeter divisions running the long way of the prop-
tometer. The scale is pressed against the outer angles of
the orbits. Then sighting along the parallel lines of the
side of the eye examined, it is noted where on the scale
the most prominent point of the cornea seems to fall.
The protrusion of the cornea in front of the line joining
the outer angles of the orbit varies from 8 to 20 mm.
under normal conditions.
The I/ashes. — The position and regularity of the
lashes should be noted. A marked deformity of the
individual cilia, inequality of length, and displacement
56 EXAMINATION OF THE LIDS.
generally indicate long-continued inflammation of the
margin of the lids. Considerable displacement of the
row of lashes inward — trichiasis — or similar displacement
of the whole lid-margin, so that the lashes turn in against
the eyeball — entropion — commonly indicates chronic dis-
ease of the conjunctiva. Displacement of the lid-margins
outward — ectropion — may arise from cicatricial contrac-
tion of the skin of the lid, or from relaxation of the
orbicularis muscle.
Occasionally the cilia are found to support nits or ova
of the pediculus pub is,
Movements of the I/ids. — The lids may exhibit
involuntary movement, from slight fibrillar twitching in
the middle or temporal portions of the lower lid to a
general spasm (blepharospasm), which may prevent their
being opened fo^a considerable period of time. It is to
be noted whether the patient can open the lids to the
normal extent, and equally on the two sides. If not,
ptosis is present, and it should be observed whether the
tendency of the lid to droop can be overcome by increased
muscular exertion, and whether it depends on binding
down of the lid, or apparent loss of muscular power. If
the inability to raise the lids appears complete, the sur-
geon should notice whether the attempt to raise them
causes any retraction of the upper lid, just beneath the
brow. Any retraction at this point indicates some power
in the elevator of the lid. If, however, the movement
of the lid depends entirely upon the muscles of the brow
and forehead, special effort to raise it will be attended
rather by the obliteration of any groove in this situation.
Where it is suspected that paralysis of the elevator is
pretended, this groove should be watched while the
patient is directed to look upward.
Abnormal retraction of the lids and failure of the
upper lid to follow the movements of the eyeball when it
is turned down are signs of exophthalmic goitre. It
should be remembered that the instillation of cocain
causes an increased retraction of the lids, and physo-
EXTERNAL EXAMINATION OF THE EYE. 57
stigmin (eserin) causes fibrillary twitching of the lower
lid.
When the lids have been opened, the position of the
lacrimal puncta should be ascertained, and whether the
tears are properly carried away, or accumulate at the
lid-margin.
Motility of the Eyeballs. — This will frequently
need to be studied by the special tests described in Chap-
ter VIII, but it should also be considered in the routine
examination. The patient is first asked to look in differ-
ent directions and the movements of the eyes watched.
Then he may be requested to look steadily at the end of
a pencil, held a half-meter in front of the eyes and moved
into different parts of the field of vision, while the sur-
geon observes whether both eyes properly follow it in
all directions. Especially should it be noticed whether
the eyes steadily fix upon it near the limits of the visual
field, or whether they here begin to oscillate — an indica-
tion of weakness of the muscles brought into use.
The pencil should then be held directly in front of the
face a little lower than the eyes and gradually brought
nearer, until it is so close that they can no longer be
turned in enough to enable both to fix upon it. This
determines the power of convergence. At the near point
of convergence one of the eyes remains fixed upon the
object and the other turns outward. With normal con-
vergence this occurs only when the fixation-point is
brought within four inches of the eye. The inability to
execute these movements points to weakness of the
muscle or muscles upon which such movements depend.
Inversion of the lids is required for their complete
examination. The lower lid is turned out by placing a
finger upon the skin near its free margin, and drawing
the lid-margin down with a slight pressure of the finger-
tip, the eye being at the same time rolled strongly upward.
A little movement of the finger-tip, changing the direc-
tion of the traction, serves to expose in succession all
parts of the lower sac of the conjunctiva.
58
EVERSION OF THE LIDS.
Eversion of the upper lid is really a folding of the lid
upon itself. The method of doing it may be understood
from Fig. 14. The lid must first be drawn out from
beneath the brow, far enough to give room for the fold-
ing. On this account the eye must be turned strongly
down, the patient looking at the floor throughout the
whole manipulation, because thus the elevator of the
upper lid is relaxed. The lashes and lid-margin are
lightly seized between the thumb and forefinger and the
lid drawn gently out and down, as shown in Fig. 14.
With the other hand, the end of a probe, lead-pencil, or
match-stick is placed against the
lid, just above the upper margin
of the tarsal cartilage ; and, while
by gentle pressure with its point,
the lid is kept from slipping up
under the brow, the tension is
relaxed at the margin, and the
margin swept up as shown by
the dotted line, until the cartilag-
inous portion lies in the position
shown by the broken lines, folded
over on the retrotarsal part of the
lid, fairly everted. To retain it
in this position it is only needful
to keep the free margin well
pressed back against the lid ; the
stiffness of the normal cartilage will keep the lid from
unfolding and slipping back.
The critical point in this little manipulation is when
the tension made by thumb and finger is relaxed, and the
folding attempted. If at this time the patient looks up,
or if the probe is placed on the cartilage (instead of at its
upper margin), so that pressure of the probe prevents the
sweeping over and turning out of the cartilage, the ever-
sion becomes impossible. If the lid is thickened and the
cartilage rounded, as by chronic inflammation, it becomes
difficult to evert the upper lid, and sometimes impossible
to keep it everted. With a normal lid and the full CO-
FIG. 14.— Eversion of the
upper lid. The dotted arc
shows where the. lid-margin
is carried up, and the dotted
lines above show the posi-
tion in which the lid is held
everted.
EXTERNAL EXAMINATION OF THE EYE. 59
operation of the patient in looking steadily down, the
eversion is easy and painless. The beginner should place
the probe about parallel with the upper margin of the
cartilage, where it can remain until the eversion is fully
accomplished. The expert will often dispense with the
probe altogether, using the tip of a finger instead.
Inspection of the everted lids reveals the state of the
conjunctival vessels, the smoothness or roughness of the
surface, the existence and character of exudate, the pres-
ence of a foreign body, or the localized grayish discolora-
tion of chalazion. Roughening of the, surface by minute
points that do not appear to differ from the general sub-
stance of the conjunctiva, a roughening that is compara-
tively uniform like that of sand-paper, is often called
" granulated lids." It is entirely different from true
granular conjunctivitis or trachoma, in which the protrud-
ing masses are larger, and set in an abnormally red,
thickened conjunctiva, like small grains of partly cooked
sago or tapioca. Scars may also be found on the lids, but
a normal lack of vessels near the center as compared with
the redder ends of the lid, caused by the pressure of ever-
sion, should not be misunderstood.
Eversion of the upper lid usually does not expose the
whole upper sac of the conjunctiva. To examine the
retrotarsal fold it may be necessary to turn the eye
strongly down, hold the lid away from the globe without
eversion, and look up into the sac from below. For this
purpose some form of lid elevator is necessary, such as is
FIG. 15.— Lid elevator.
shown in Fig. 15: The edge of this instrument is gently
insinuated between the lids, and the upper lid retracted
with it, and held away from the eyeball. Its use is some-
times necessary for the inspection of the eyeball itself, as
in young children who resist the examination, or when as
60 EXAMINATION OF THE LIDS.
after injury or in purulent conjunctivitis the swelling of
the lid prevents its normal opening or eversion.
The study of the intra-ocular tension is described in
Chapter XV.
HYPEREMIA.
Hyperemia about the eyes may involve one or more of
three distinct vascular regions. The first of these is the
lid-margins. Redness, usually with swelling, of the
lid-margins is symptomatic of inflammation in the hair-
follicles or glands.of these portions of the lids, and usually
arises in connection with chronic congestion or inflamma-
tion of the conjunctiva. Where such hyperemia is per-
sistent or frequently occurs, some persistent cause should
be sought. This may be a tendency to catarrh, affecting
the conjunctiva ii» common with other mucous membranes,
as with the so-called strumous diathesis. More commonly
it is a persistent congestion due to eye-strain.
Hyperemia of the conjunctiva may exist without
any considerable discharge. There is increase in the size
and apparent number of vessels, and general redness of
the membrane. The conjunctival vessels come forward
from the bottom of the conjunctival cul-de-sac above and
below the eyeball. Here the largest trunks become vis-
ible, dividing as they pass forward, some to be distributed
to the bulbar, and some to the palpebral conjunctiva and
subconjunctival tissue, subdividing and growing smaller
as they approach the cornea and free margins of the lids.
The tissue to which this system of vessels is distributed
is thickest at the cul-de-sac, and thins out forward,
especially on the globe. Hyperemia of this system of
vessels therefore shows the greatest increase of redness in
the retrotarsal region, the redness fading out into the
normal color, as we go forward toward the cornea or
toward the free margin of the lid. The increased redness
is most apparent back from the cornea in the region of the
cul-de-sac. This sort of ocular hyperemia is represented
in Fig. 16. It is frequently noticed in acute general dis-
ease. It may be present with fever from any cause, and
EXTERNAL EXAMINATION OF THE EYE. 61
attends certain diseases such as measles. It may be pro-
voked by exposure to an atmospheric irritant, such as
dust, smoke, irritant gases, etc. It may mark the first
effects of a specific irritant, such as the virus of gonor-
rhea. It may be reflex, as from irritation in the nose, or
may be produced by a foreign body imbedded in the cor-
nea and scratching the lid.
Localized Conjunctival Hyperemia. — Prolonged ex-
posure to the light and the heat of the sun, especially
reflected from surfaces of white sand or water, or to the
light and heat of a hot fire is liable to produce hyperemia,
sometimes with swelling of the part of the conjunctiva
FIG. 16.— Conjnnctival hyper- FIG. 17.— Hyperemia of phlyc-
eraia. tenular conjunctivitis.
directly exposed — that is, the conjunctiva of the globe in
a triangular area to the outer and inner sides of the
cornea.
Hyperemia affecting some particular portion of the con-
junctiva of the globe and the adjoining inner surfaces of
the lid is usually due to traumatism, or the contact of
some chemical irritant or hot substance. Portions of the
lower cul-de-sac are most liable to be thus affected.
Hyperemia characterized by the enlargement of the ves-
sels running from one part of the cul-de-sac forward upon
the globe, usually to the corneal margin and sometimes
extending upon the cornea, is significant of phlyctenular
disease. This form is represented in Fig. 17.
Pericorneal Redness. — In contrast with conjunc-
tival hyperemia, which is most pronounced at the pe-
riphery of the sclera, and fades out as the cornea is
approached, is the redness due to the enlargement of the
minute vessels which encircle the cornea in the scleral
62 PERICORNEAL REDNESS.
margin, and furnish to the non-vascular cornea a large
part of its nutrient supply. These vessels are supplied
mainly by the deep arteries and empty mainly into the
deep veins of the eyeball, although they anastomose freely
with the peripheral loops of the conjunctival vessels.
They have intimate connections with the vessels of the
iris and the ciliary body. Normally they are quite in-
visible ; but when dilated they cause a distinct pink or
rosy zone, more or less completely encircling the- cornea
and from 3 to 5 mm. in width (Fig. 18).
Such hyperemia is indicative of inflammation of the
cornea, iris, or ciliary body, or all of these. When severe,
FIG. 18.— Pericorneal hyper- FIG. 19.— Enlarged veins in
emia. chronic glaucoma.
it involves the whole circle of vessels, but may be most
noticeable in some one direction.
It is a valuable symptom pointing to a foreign body in
the cornea, when such foreign body has been lodged there
for sonle days. In corneal ulcer the pericorneal redness
has a similar relation to the seat of the lesion. In iritis
an incomplete zone of pericorneal redness indicates a por-
tion of the iris in which the inflammation has been more
violent and subsides more slowly, such an incomplete zone
being usually seen during the decline of the disease.
Deep Hyperemia of the Sclera. — This may con-
sist in a general enlargement of the vessels that run
comparatively straight toward the cornea, and which lie
deep in the tissue ; in contrast to the conjunctival ves-
sels, which are more tortuous, and move freely with the
conjunctiva when this is rubbed about with the lid. The
involvement of the scleral vessels indicates inflammation
or congestion of the interior of the eyeball.
Another form of scleral hyperemia is that in which the
EXTERNAL EXAMINATION OF THE EYE. 63
smaller vessels over one or more isolated patches of sclera
are involved along with the straight large trunks of that
region, giving a patch having a pink or deeper purplish
red color. This appearance indicates a local inflamma-
tion of the sclera.
Enlargement of the Scleral Veins. — Enlargement
of the scleral veins (Fig. 19) is still another form of hyper-
emia. The principal trunks of these vessels emerge from
the scleral, 4 to 10 millimeters back from the corneal
margin, and pass backward over the globe. One or more
of them can usually be detected in the normal eye. In
the condition now referred to they become greatly en-
larged, prominent, and connected one with another by a
a network of large vessels surrounding the cornea, a little
distance back from it. This kind of venous congestion
is indicative of chronic increase of intra-ocular tension —
glaucoma.
Mixed Forms ,of Hyperemia. — The typical varie-
ties of hyperemia above described are often seen, but in
many cases two or more of them are blended together.
Thus, a foreign body in the cornea, by scratching the
palpebral conjunctiva and by reflex influence, will pro-
duce an active hyperemia of the conjunctiva, while its
presence in the cornea for a few hours will also give rise
to hyperemia of the pericorneal zone. Severe iritis, par-
ticularly in its early stages, is likely to be accompanied
with conjunctival hyperemia. Glaucoma in its inflamma-
tory forms includes an inflammation of the iris and a
marked pericorneal zone of enlarged capillary vessels. In
general, any severe inflammation will probably cause some
extension of hyperemia beyond the tract of vessels whose
involvement would be typical of the disease.
SWELLING.
Swelling, being due to the increase in the size of the
vessels or the escape of exudate from them, is necessarily
closely allied to hyperemia, but either may exist with-
out the presence of the other being noticed.
64 SWELLING.
Swelling of the I/ids. — It will be remembered that
the cellular tissue of the lids furnishes one of the com-
mon localities for serous exudation in chronic renal dis-
ease, or in acute general edema from any cause. The
extent of the swelling in such cases varies with the effect
of gravitation, according to variations in the position of
the patient, being greatest after lying down. Great
swelling of the lids may result from emphysema, due
commonly to wounds of the nose. The infiltration by
air is recognized by the softness and crackling of the
tissue under pressure, and increase of swelling by blowing
the nose.
In other cases general swelling of the lids is inflamma-
tory ; and the focus of the inflammation causing it may be
either in the lids or in the neighboring structures. A
very small focus*of inflammation may lead to great gen-
eral swelling of the lids through interference with venous
currents caused by pressure or thrombosis.
General swelling of the lids may also arise from inter-
ference with the orbital circulation by pressure, from a
focus of inflammation or a new growth deep in the orbit.
Again, great and sudden swelling of the lids without
other obvious reason should lead to the suspicion of grave
intraocular disease. The loose tissue allows the lid to
swell rapidly without much pain. As the swelling sub-
sides the skin becomes wrinkled.
A somewhat chronic, firm swelling of the lids has been
designated solid edema, or lymphoid infiltration. It accom-
panies certain obscure general conditions, as Hodgkin's
disease, in which connection it may be of diagnostic
importance.
Localized swelling of the lids may indicate a focus
of inflammation such as a small abscess, but a distinct
tumor is more frequently chalazion. Occasionally, small
cystic tumors form in connection with the glands of the
skin in this region. Dermoid cysts occurring in the
region of the orbit — one of their favorite positions — may
occasion swelling of the lids. Swelling of the lids may
also be due to deeply seated growths, such as gumma of
the periosteum of the orbit, osteoma, fibroma, or sarcoma
EXTERNAL EXAMINATION OF THE EYE. 65
of the orbit, or to empyema of the frontal or ethmoidal
sinuses. Swelling of the nasal extremity of the lower
lid and of the side of the nose and adjoining parts is fre-
quently caused by obstruction of the lacrimal duct. The
dilatation of the sac alone may cause a noticeable tumor, or
inflammation around the sac may be added to the dilata-
tion.
Prominence of the Eyeball ; Exophthalmos. —
Apparent prominence of the eyeball may be due simply
to the wide opening or retraction of the lids, or such
retraction may exaggerate a real prominence, as in exoph-
thalmic goiter. Elongation of the eyeball in high degrees
of myopia makes it appear prominent. The nature of
the trouble here becomes more evident when the patient
turns the eye strongly toward the nose. Actual forward
displacement of the eyeball may result from paralysis of
one or more of the ocular muscles. Complete paralysis
of the oculomotor nerve always produces some such dis-
placement. It may be due, also, to actual swelling of
the orbital tissue, either from inflammation (orbital cellu-
litis), from hemorrhage, from new growth, or from venous
stasis (see Chapter XVI).
Swelling of the Conjunctiva. — Swelling of the
conjunctiva, affecting the palpebral portion, shows itself
by the thickening of the lids. Swelling of the ocular
conjunctiva, if moderate in amount, is seen chiefly back
from the cornea ; but if more extensive it involves the
membrane up to the corneal margin, and may cause it to
rise around the cornea like a wall, or even quite overhang
the corneal margin. This is the condition known as
chemosis. It is apt to arise in violent conjunctival in-
flammation, such as severe purulent conjunctivitis, and
from severe injury or very acute inflammation within the
eyeball. The swelling of chemosis is produced by a
serous exudation, and the thickened conjunctiva is com-
paratively transparent. Another form of thickening, as
abrupt as chemosis, but much less in height, flattened
rather than rounded, and often exhibiting a peculiar
appearance of radiating pleats, attended with little or no
66 SWELLING OF THE CONJUNCTIVA.
swelling in other parts of the conjunctiva, is characteristic
of vernal conjunctivis. A somewhat similar appearance
without hyperemia is not rarely seen in the colored race,
as an anomaly.
Great swelling of the ocular conjunctiva, with cell-
infiltration, occurs in trachoma and diphtheritic conjunc-
tivitis, or may mark a late stage of purulent conjunctivitis.
CONJUNCTIVAL DISCHARGE.
From the healthy conjunctiva, the slight secretion and
loosened epithelium are washed away by the tears ; and
very considerable increase over the normal secretion, if
attended with a proportionate increase of the tears, may be
removed in the same manner without attracting attention,
or showing an^ sign upon casual examination. When
this is the case, the pathological discharge may only
become evident when, after the lids have been closed
during sleep, the evaporation of tears leaves a deposit of
such discharge upon the lid-margins, or causes them to
stick together in the morning. Such adhesion of the lids
will often reveal the occurrence of a discharge when no
other evidence of it can be detected.
Conjunctival discharge, if moderate in amount, con-
sists largely of an increase of the normal constituents —
mucus and epithelium — but as it increases in amount it
includes an increasingly large proportion of pus-cells.
No sharp line can be drawn between mucous or catarr/uil
and purulent discharges, one running gradually into the
other. In specific purulent inflammation the discharge
may be extremely profuse. In a few cases the exudate
becomes croupous or diphtheritic in character. A de-
posit upon the surface which, when removed, occasions
bleeding, but which can be removed without great force,
is termed croupous. The diphtheritic deposit is more
intimately .incorporated with the tissue, and cannot be
separated from it. Where diphtheritic deposit occurs,
the escaping discharge, instead of being purulent, is com-
monly serous or flocculent. It must be borne in mind
EXTERNAL EXAMINATION OF THE EYE. 67
that recent investigations show that a diphtheritic deposit
may occur in the conjunctiva quite apart from the specific
disease — diphtheria — and that true diphtheria may involve
or even destroy the eye without any characteristic diph-
theritic deposit.
Microscopic Examination. — In general, the micro-
scopic or bacteriologic examination of a conjunctival dis-
charge furnishes more definite information regarding the
true character of the case than the macroscopic appearances.
The discharge is taken from the conjunctiva with a
loop of platinum wire sterilized by passing through an
alcohol flame, and placed on a clean cover-glass. Another
cover-glass is placed over this, and the two firmly pressed
together to diffuse the discharge in a uniform film over
them. Each glass is now grasped in a spring clip that will
prevent any mistake as to which side the film is upon, and
allowed to dry. A few drops of the stain are then placed
on the film for the required number of minutes, and it is
afterward washed with distilled water, and decolorized if
desired. It is then thoroughly dried and mounted with a
drop of Canada balsam.
The most useful stains are : Strong alcoholic solution
of methylene-blue, 30 ; one per cent, solution of caustic
potash, 100. This stains most bacteria in ten to fifteen
minutes.
Anilin oil, 1 ; distilled water, 100 ; gentian-violet to
saturation. Add alcohol (3 parts), and filter. This
also stains most bacteria satisfactorily.
For the Gram method, after staining for ten to fifteen
minutes with the above gentian-violet, place the film for
one or two minutes in —
lodin, 1 ; potassium iodid, 2 ; distilled water, 300.
Then wash it, and place in alcohol until the color is
nearly gone ; dry and mount.
The most conclusive study of the bacteria of the con-
junctiva is made by inoculating with the matter on the
loop, tubes of agar, agar-serum, and blood-serum, and
studying macroscopically and microscopically the cultures
thus obtained.
68 OBLIQUE OR FOCAL ILLUMINATION.
OBLIQUE OR FOCAL ILLUMINATION.
The patient is placed facing the surgeon and in such a
position that the light shall shine across his face, prefer-
ably from the side of the eye to be examined. The exam-
ination is commonly made in a dark room, using strong arti-
ficial light concentrated upon the eye by a strong lens,
focal illumination. The relative positions of the lamp-
flame, L, the lens, and the patient's eye, E, are shown in
Fig. 20. The lens should be held so as not to focus perfectly
the light upon the eye, for a uniform diffused illumination is
FIG. 20. — Manner in which the pencil of rays should be focussed on the eye for
oblique illumination.
better than one which varies in intensity in different parts
of the lighted area, as completely focussed light usually
does. Where oblique illumination is resorted to with
good daylight, as by placing the patient with his side to
a large window, but little is gained by the use of the con-
densing lens. Using the lens it is possible by varying its
position to throw light first on the surface of the cornea,
leaving the iris and pupil in comparative shadow, then to
throw the light upon the iris, leaving the cornea in
shadow. This is a great aid in determining the location
of a particular point, when there is considerable opacity
of the cornea. .
Many of the appearances studied by focal illumina-
tion require for their full appreciation the use of a
magnifier. This may be an ordinary convex lens of
about 20 D. (two inches focal distance) ; or a stronger
lens, often called a " corneal loupe" may be employed.
The lens is held at slightly less than its focal distance
from the eye to be examined, the surgeon placing one
BINOCULAR MAGNIFIER.
69
of his eyes in line with it at a convenient distance.
The compound microscope has also been adapted to the
examination of the eye by oblique illumination, by giv-
ing it a very large objective, and mounting it with the
proper facilities for adjustment. With such magnifiers
only monocular vision is possible.
To gain the important advantages of binocular vision,
a binocular magnifier must be employed. This consists
essentially of two convex lenses joined at an angle, the
right eye looking through one, the left through the other.
With the lenses are combined prisms which lessen the
required effort of convergence. The form most readily
FIG. 21. — Binocular magnifier sup-
ported by a spring steel headband,
for examination of the eye, and the
performance of certain operations.
FIG. 22.— Jackson's binocular magni-
fying lens. The broken lines show the
directions of the two lines of sight
meeting in the point looked at.
used is shown in Fig. 21. A form more easily carried in
the pocket and quite as useful when one has acquired the
mastery of it is shown in Fig. 22.
With either form, the magnifier must be held with the
line joining the centers of the lenses parallel to the line
joining the centers of the surgeon's pupils. It is well to
start with the magnifier quite close to the patient's eye,
and after binocular vision has been secured, to withdraw
the lenses almost to their focal distance from the eye, to
get the benefit of their full magnifying power.
Focal illumination is employed to discover foreign
bodies in the cornea or anterior chamber, or upon the
70 t BINOCULAR MAGNIFIER.
iris; to study opacities or ulccrations of the cornea, and
to determine abnormalities of the iris.
Most opacities of the cornea thus illuminated give
rise to a gray appearance. An arc of gray near the upper
and the lower margins of the cornea, but with some
clearer cornea between it and the sclerotic, is the so-called
arcus senilis. As age advances, the arcs extend until
they form a complete ring. This appearance is not con-
fined to the very old, but may occur even in very early
childhood. It is more apt to occur early, in the negro
race. It has no definite or special significance, either MS
an evidence of the state of the general nutrition or of the
eye itself.
Opacities in the cornea vary in proportion to the depth
of tissue affected, and the extent of its departure from
normal. When«light and superficial, an opacity is called
a nebula. If of limited extent and more decided, so that
it can be detected by ordinary inspection, but yet does
not entirely hide the iris behind it, it is a macula. If
still denser, so that the structure and color of the iris
cannot be seen through it, from its whitish-gray color it
is called a leucoma. Opacities of the cornea containing
points of black or brown discoloration generally mark the
site of a former perforating ulcer, in the healing of which
the iris has become entangled in the cicatrix, and remains
adherent to it, constituting an adherent leucoma.
The reflections from the surface of the cornea
should be carefully observed, the position of the eye with
reference to the light being varied, so as to get the reflec-
tion of the source of the light from all parts of the cornea
successively. Any irregularity in the surface, as from a
foreign body or a corneal ulcer, will become evident in
the irregularity of the reflection. Very minute foreign
bodies or abrasions may be covered by the corneal mucus,
so as to give rise to no irregularity in the reflection until
the cornea has been gently wiped with absorbent cotton
(see Chapter XVII), when even the most minute irregu-
larities become manifest. Distortions of the corneal sur-
face, as by cicatricial changes following previous inflam-
OBLIQUE ILLUMINATION. 71
mation, cause, not the sharp break in the reflection pro-
duced by recent injury, but a distortion of the shape of
the reflex. The cornea being normally flattened toward
its periphery the reflections are always larger there than
near the center. Distortions of the corneal reflex are best
studied with the Placido disk, which consists of alternate
circles of black and white. It is held before the eye to
be examined, the patient being placed with his back to
the light and the observer's eye at the opening at the
center of the disk.
The symptoms presented in the anterior chamber are
discussed in Chapter XIV.
Inspection of the Iris. — Oblique illumination best
reveals any inequalities of thickness or irregularity of
structure in the iris, although differences of color, espe-
cially those indicating hyperemia, are best seen by direct
examination in clear daylight. Thickening may be due
to parenchymatous inflammation, in which case the iris
will be devoid of reflex and altered in color, from blue or
gray toward greenish by the excess of blood in it, and
the swelling general ; or there may be sharply localized
swelling of decidedly different color from the surrounding
iris, which indicates a new growth, as gumma, or tubercle
usually accompanied with iritis, or sarcoma which grows
at first slowly and without evidences of inflammation.
Cysts of the iris are usually still slower in development,
and of rounded outline.
THE PUPIL.
By oblique illumination, the pupil may be made to
contract when the light is thrown more directly into it ; or
dilate as it is thrown in more obliquely. Slight departure
of its form from a perfect circle and slight inequalities in
the size of the two pupils are common. Decided irregu-
larity of the shape of the pupil is usually abnormal.
Most frequently it is due to adhesions of the iris, either to
the cornea, anterior synechia, or to the capsule of the lens,
posterior synechia. Anterior synechia generally occurs in
connection with adherent leucoma, and the pupil is often
72 THE PUPIL.
partly hidden by the opacity of the cornea when looked
at from in front. But by throwing the light quite
obliquely into the eye, and placing the eye of the observer
near the direction from which the light comes, the pulling
forward of the adherent portion of the iris can be dis-
covered. Posterior synechia becomes most evident when
the pupil is dilated, either by the use of a mydriatic or
by examining the eye in the dark room.
The si^e of the pupil is not usually so important as
its reaction. It should be measured both in a strong
light and in as feeble illumination as will allow of an
accurate measurement. The measurement may be made
with an ordinary millimeter scale held as close as possible
to the patient's eye, the surgeon's
eye being some distance away.
This under-estimates the diam-
eter of the pupil in proportion as
the scale is nearer the surgeon's
eye than is the pupil measured.
Another method is to have a
series of black circles on a card,
or of circular openings in a metal
disk, varying in size from 1 to 10
FIG. 23.- simple pupiiiometer. mmv with | mm. intervals, as
shown in Fig. 23. This is to be
held alongside the patient's eye, and the circle or open-
ing found which most nearly corresponds to the size of
the pupil.
Pupillary Reactions. — The pupil is most mobile in
early childhood, being at that time commonly large in
moderate illumination, dilated widely in the dark, yet
strongly contracted on exposure to bright light. With
increasing age it becomes more rigid and mostly smaller.
If the pupils are small, their reaction can best be studied
in a feeble light, as by oblique illumination in the dark
room. If large, as after the use of a mydriatic, the reac-
tions may be more distinct in a stronger light. Absolute
measurement of the extent of the reaction has by itself
but limited significance. Inequalities of reaction and
REACTIONS TO LIGHT. 73
alteration in the essential character of the reaction are
more important.
Reactions to Light. — Normally, contraction of the
pupil is brought about by increase of the light entering
the eye, or by throwing the light upon a more sensitive
part of the retina, such as the macula. It may be tested
by alternately shading and uncovering the eyes in day-
light ; but if not shown in this way, the test is made in
the dark room, by concentrating the light from the lamp-
flame upon the pupil, with the ophthalmoscope mirror
held at its focal distance in front of the eye. Turning
the mirror so that the light will fall on some other part
of the face, the pupil is permitted to dilate ; then the
pencil of light being suddenly thrown upon the eye, the
appreciable time required for the reaction allows the
observer to note the size of the pupil as it was in com-
parative darkness, before the sudden contraction due to
the effect of the light. Under these conditions the slight-
est reaction to light can be detected. The turning of
the light on and off the eye is to be repeated, until the
surgeon is fully satisfied as to its effect. The first con-
traction to light is often followed by a perceptible dilata-
tion, this by a new contraction, and so on, each dilatation
and contraction growing less until the pupil becomes
stationary. Exaggeration of this is hippus.
Failure of the pupil to contract may be due to the use
of a mydriatic, to adhesions or rigidity of the iris, to loss
of function in the retina or optic nerve-tracts, or to inter-
ference with the motor tract from the pupillary centers to
the iris. By mydriatics, iritic adhesions, or motor paraly-
ses, all movements of the pupil are interfered with. If,
however, other movements are normal, the cause of any
impairment of the light reaction must lie in the visual
sensory tract, or in the fibers connecting this with the
centers for pupillary contraction. The course of the
sensory tract is shown in Fig. 24 ; from the retina,
through the nucleus of the corpora quadrigemina, to
the visual center in the occipital lobe. If the sensory
tract be involved, vision will be impaired as much as or
74 REACTION TO LIGHT.
more than the pupillary reaction. Hence, if vision be
good and the pupil fails to react only to light, the fault is
known to lie in the fibers connecting the optic tract (sen-
sory), with the centers (motor) for pupillary contraction.
A pupil showing absence of the reaction to light, where
vision and other pupillary movements remain good, is
FIG. 24. — Tracts concerned in the pupillary reflex, the efferent or motor tract
b^lng represented by the dotted lines.
known as the Argyll- Robertson pupil. It is an important
early symptom of locomotor ataxia or multiple sclerosis.
It should be borne in mind that each pupil reacts
freely to light thrown in the other eye — consensual reac-
tion— and that even changes of light upon the closed lids
of the other eye may cause a noticeable reaction. Where
loss of reaction to light is due to involvement of fibers
connecting the sensory and motor tracts, the pupil com-
monly remains contracted in the darkened room. This
has been taken to indicate that the condition was one of
excessive innervation of the sphincter of the iris, a view
supported by the occasional dilatation of the pupil and
the restoration of the light reflex in late cases of sclerosis,
after complicating lesions like apoplexy. Interference
with the sensory tract causes complete blindness before
it destroys the pupillary reaction to light. When loss of
light-reaction does occur, it is important evidence corrob-
orative of a patient's statement that an eye has become
quite blind.
The light-reaction is lost only when the interruption
of the sensory tract is in front of the corpora quadrigem-
ina where the fibers which connect it with the motor
GENERAL REACTIONS OF THE PUPIL. 75
tract are given off. Blindness due to a lesion back of
this point may be absolute without interference with the
pupillary reaction. This fact is of importance in localiz-
ing a lesion causing hemianopsia. A single lesion of the
sensory tract back of the optic chiasm causes hemianopsia.
If the lesion lie between the chiasm and the corpora
quadrigemina, it also destroys the reflex of the pupil to
light thrown upon the blind half of the retina, although
the reflex remains perfect to light thrown on the seeing
half of the retina. This is the so-called Wernicke reac-
tion of the pupil or hemiopic pupillary inaction. If the
lesion causing the hemianopsia be back of the corpora
quadrigemina, it will not interfere with the reaction of
the pupil to light thrown upon any part of the retina.
Hence, hemiopic loss of the pupillary reflex points to
lesion of the optic tract, between the chiasm and the
corpora quadrigemina, or within the latter. The search
for this reaction must be carefully made in a dark room,
with light carefully excluded from the seeing halves of
the retinas.
Slowness of the reaction of the pupil to light, or ine-
quality of the two pupils, or of the same pupil at different
times, is an indication of chronic degenerative changes in
the central nervous system. Complete loss of the lights
reaction may be caused by any lesion of the optic nerve
or eye that causes complete blindness. Vision, however,
may be very greatly impaired with but little loss of the
pupillary light reflex ; and even when blindness seems
complete, and by ordinary tests the pupil seems not to
react to light, complete darkness may cause slow dilata-
tion, and exposure to strong sunlight a slow contraction.
General Reactions of the Pupil. — Normally the pupil
dilates under nervous excitement, fear, surprise, dur-
ing hunger, in anemia, or from other causes of nervous
instability. It contracts with the effort to focus the eyes
for near objects, and with the convergence or turning in
of the visual axes. It also contracts strongly during
sleep.
The test of contraction with convergence and accom-
76 ASSOCIATED CONTRACTION.
moclation — associated contraction — is to be made by
getting the patient to look first at a distant object, and
then at the point of a pencil or similar object held close
to the eye in a line with the distant object, to avoid any
change of illumination. Looking alternately from one to
the other, the changes in the size of the normal pupil are
readily observed. Failure of the pupil to contract with
convergence, or great sluggishness of contraction, indi-
cates some fault in the motor apparatus. Dilatation of
the pupil and sluggish reaction with convergence occur in
glaucoma, and large pupils in elderly persons should
always bring this disease to mind.
If not due to glaucoma or injury in the eye, or the use
of a mydriatic, moderate dilatation of the pupil, with
failure to contract to any stimulus, indicates lesion of the
oculomotor nerv*or its nucleus in the pons. Generally
if the dilatation of the pupil be accompanied by the loss
of power in the external muscles supplied by the third
nerve, the lesion is located somewhere in the nerve-trunk.
If the dilatation or partial dilatation of the pupil and
failure to contract under stimulus be accompanied only
with loss of accommodation, they constitute the condition
known as ophthabnoplegia interna, and depend upon some
lesion involving the nucleus from which the nerve pro-
ceeds.
Persistent contraction of the pupil is due to narcotic
poisoning (opium) or to cerebral irritation, as from inflam-
matory disease of the brain and its membranes, or from
the congestion which attends cerebral apoplexy or the
early stages of the acute fevers. It may, however, occur
from a lesion involving the inhibitory fibers of the cervi-
cal spinal cord. But the most common cause of contracted
pupil — always to be thought of and sought for — is the
adhesion of the iris to the lens capsule — posterior syne-
chia. Such adhesion, if extensive, causes absolute im-
mobility of the pupil, generally in a state of great con-
traction.
Persistent dilatation of the pupil, aside from blindness,
glaucoma, and the use of mydriatics, is liable to be caused
GENERAL REACTIONS OF THE PUPIL. 77
by irritation of the upper portion of the spinal cord, as
in the early stages of organic disease.
The color of the pupil by oblique illumination is not
usually clear black, but the anterior surface and the sub-
stance of the lens reflect some light, giving it a slightly
gray tinge. This becomes more decided as the patient
grows older, and after middle life is always very notice-
able and liable to be mistaken for cataract. It is ren-
dered most evident by allowing the light to fall upon the
eye very obliquely, and viewing the pupil obliquely over
the bridge of the nose from the opposite side.
In this way there may be observed, sometimes even in
children, a group of radiating lines situated in the an-
terior surface of the lens, which is, however, quite phys-
iological and not to be mistaken for commencing
opacity.
By dilating the pupil and bringing the source of
illumination rather more in front of the eye, the whole
thickness of the lens can be inspected and opacities
•revealed in any part of it, or in the anterior portion of
the vitreous humor. The results obtained by focal
illumination, however, should not be relied on, in any
doubtful case, without confirmation by examination with
the ophthalmoscope.
Transillumination. — Illumination of the interior of
the eye through the sclera is of value for revealing the
presence and extent of tumors or foreign bodies lying
close behind the iris or ciliary region, or to reveal atro-
phic thinning of these parts. An electric lamp is enclosed
in an opaque cover from which projects a glass rod, also
covered by an opaque coating, except at the end which is
brought in contact with the sclera. The light shining
through the rod enters the eyeball through the normal
sclera and choroid, causing a red glow in the pupil. But
when the rod is placed over a tumor, or opaque foreign
body, this glow diminishes or disappears entirely.
78
THE OPHTHALMOSCOPE.
CHAPTER IV.
OPHTHALMOSCOPIC DIAGNOSIS.
THE OPHTHALMOSCOPE.
THE ophthalmoscope enables the surgeon to inspect
the interior of the eyeball through the cornea and the
crystalline lens, which mag-
nify the details of the fundus
1 0 to 20 diameters, according
to the refraction of the eye.
It consists essentially of a
mirror for throwing the light
into the eye, with a central
perforation through which
the surgeon can look in the
direction that the light is
thrown, and a series of lenses
to focus the light from the
structures examined.
The form of ophthalmo-
scope preferred by the author
is illustrated in Fig. 25.
The mirror is swung upon
a pivot, placed at each end,
so that it can be tilted to an
angle of 25 to 30 degrees
with the back plate that
shades the surgeon's eye from
the light. The aperture in
the mirror is about 2 milli-
meters in diameter. The
lenses are arranged in two
slides just behind the mirror.
They are moved by the tip
of the forefinger acting on
milled projections from the
FIG. 25.-Autbor's ophthalmoscope, lower ends of the slides. This
OPHTHALMOSCOPIC DIAGNOSIS. 79
allows the use of all lenses and combinations of lenses
of which the instrument is capable without removing it
from the eye. By taking out a screw from the lower end
of the stem, the slides of lenses are readily removed for
cleaning. The lens series furnished by the instrument
includes either convex, 1, 2, 3, 4, 5, 6, 8, 11, and 15 D. ;
and concave, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, and 30 D. ;
or convex, 0.5, 2, 1.5, 2, 2.5, 3, 3.5, 4, 7.5, and 10 D. ;
and concave, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 7, 8, 9, 10, and
25 D. Either series is sufficiently complete for all prac-
tical purposes ; but the former is preferable, the 0.5 D.
intervals being of no value except to the expert who is
constantly measuring refraction with the ophthalmoscope.
There are many other good forms of ophthalmoscope,
most of them having the lenses arranged in one or more
disks. That of Loring is one of the best, except that
the large sight-hole in the mirror fits it rather to measure
refraction than to examine the fundus of the eye. The
most common fault is in the direction of elaborating the
instrument into a machine that could do things that one
never wants to do with an ophthalmoscope.
In general, a good ophthalmoscope should have a thin
tilted mirror with a small sight-hole, free from reflections.
Reflections are to be tested by trying the instrument in
the thoroughly darkened room. Any imperfection of
the kind causes a luminous haze in front of the surgeon's
eye, which interferes with the seeing of the conditions in
the patient's eye. The lenses must be furnished with a
spring catch that will cause each lens to stop at its proper
position before the sight-hole. All lenses should be
available without removing the instrument from the eye
and without bringing the surgeon's hand too much before
the patient's face. It should be simple, and should
include no unnecessary lenses, cumbersome " improve-
ments," or useless parts.
Why any special apparatus is necessary to inspect the
interior of the eye, and the exact function of the lenses
will be explained in the section on "the measurement -of
refraction" with the ophthalmoscope, Chapter V. Two
80 THE OPHTHALMOSCOPE.
essentially different methods of using the ophthalmoscope,
the direct and the indirect, are employed. The latter,
formerly much used, is now only resorted to in special
cases. If not otherwise stated, it will be understood that
the direct method is here referred to. The optical details
of both will be described in Chapter V.
Methods of Using the Ophthalmoscope. — The
ease with which an ophthalmoscopic examination can be
made depends upon the size of the pupil. If this be not
dilated by a mydriatic, it is necessary to make the exam-
ination in a darkened room. The patient is placed with
his back to the light, which should be readily movable
from side to side. The surgeon then places himself
exactly alongside of the patient, but facing in the oppo-
site direction, sitting on the right side to examine the
patient's right ^e and on the left side to examine the left
eye. The lamp-flame, L (Fig. 26) is then drawn far
FIG. 26.— Horizontal section showing relative position of surgeon (S), patient
(P), and lamp-flame (L) during ophthalmoscopic examination.
enough to the side of the eye to be examined for the
light from it, just escaping the temple of the patient, to fall
on the outer lashes. If it be more behind the patient's head,
OPHTHALMOSCOPIG DIAGNOSIS. 81
P, it will be cut off from the mirror when this is brought
close to the patient's eye. If it be more to the side of the
patient, it may be cut off from the mirror by the surgeon's
nose, and will require an exceedingly oblique position of
the mirror in order to reflect it into the patient's eye. The
patient is to keep his head directed forward, inclined
toward the side of the surgeon, and to turn the eyes a
little to that side. The ophthalmoscope is to be held in
the right hand and to the surgeon's right eye to examine
the patient's right eye, and the left hand and eye are used
for the patient's left eye. The mirror is tilted to face
toward the light ; and, as a preliminary, the ophthalmo-
scope is held about 12 inches from the eye to be exam-
ined, in such a way as to throw the light upon it.
The corneal reflex, a small bright image of the source
of light, appears on the part of the cornea perpendicular
to the direction in which the surgeon looks ; and beside
the corneal reflex, the pupil, previously black, becomes
occupied with a red glow — the fundus reflex — which
varies in hue according to the brightness of the illumina-
tion and the color of the fundus of the eye under exam-
ination, being brighter in light and duller in dark eyes.
OPACITIES IN THE MEDIA.
Having obtained the fundus reflex, the surgeon is to
observe whether it is interrupted by any black dots or
masses. Such black spots indicate opacity somewhere
between the choroid and the observer's eye. They may
be produced by a bubble of air on the cornea, by a for-
eign body in the cornea, by specks of exudation on the
anterior capsule of the lens, by isolated opacities of the
lens, or by opacities of the vitreous. If an opacity is
discovered, the presence of other opacities should be
determined by the surgeon moving his head to different
points of views, or the patient looking in different direc-
tions. Such movements will also produce an apparent
change in the position of the opacities seen, and thus
indicate their position.
82 OPACITIES IN THE MEDIA.
The apparent position of an opacity is always referred
to the margin of the pupil. Opacities situated iu the
plane of the pupil preserve their relation to it from what-
ever direction they are seen. Those situated in front of
the pupil appear to move across it in the direction opposite
to that of the movement of the surgeon's eye or in the
same direction as the patient's eye is turned. Those
situated behind the pupil appear to move across it in the
direction in which the surgeon's eye is moved, or in the
direction opposite to that of the movement of the patient's
eye. The reason of this is shown in Fig. 27 in which //
represents the plane of the iris, A an opacity in front of
the pupil, as a foreign body in the cornea, B an opacity
in the pupil as an anterior polar cataract, and C an
M
^
FIG. 27.— Apparent position of opacities, in front of, at, or behind the pupil.
opacity behind the pupil, such as a posterior polar cata-
ract. When the eye is looked at from the direction My
the opacity at A appears to be situated at x near the
upper margin of the pupil, and the opacity at C appears
at y, near the lower margin of the pupil. As the sur-
geon's eye moves from M to TV, the opacity at A appears
to go in the opposite direction, while that at C appears t<>
move with it, so that on reaching N, A appears to be at
y and C at x ; but from all directions, J5 maintains its
position at the center of the pupil. The nearer the
opacity is to the plane of the pupil, the slower its move-
ment ; and the farther away it is from the plane of the
OPACITIES IN THE MEDIA. 83
pupil, the more rapid its apparent movement. In this
way the depth of the opacity within the eyeball may be
roughly estimated.
An aid in this estimate is the apparent movement of
the opacity as compared with that of the corneal reflex.
In all positions, the reflex comes from the direction of
the center of curvature for the cornea. For the direction
M it will be seen at m. For the direction N it will be
seen at n. If then, the opacity at O be situated exactly
at the center of curvature of the cornea, its apparent
movement across the pupil will exactly keep pace with
the apparent movement of the light-reflex of the cornea.
If the opacity be situated deeper in the eye than the
center of curvature of the cornea, it will move more
rapidly across the pupil, and get ahead of the corneal
reflex. If it be situated in front of the center of curva-
ture of the cornea, it will move more slowly across the
pupil, and lag behind the corneal reflex. Thus one can
determine whether a foreign body is in front of or behind
the center of curvature of the cornea. The position of
the center of curvature of the cornea can be accurately
determined with the ophthalmometer (see Chap. VII).
The position of opacities deep in the vitreous humor
may be determined by measurement of their refraction
with the ophthalmoscope. Opacities in the cornea and
lens are commonly fixed ; in the aqueous humor they float
freely, and in the vitreous they move with a freedom
dependent on its fluidity or loss of normal consistency.
Opacities arise in the cornea from foreign bodies,
injuries, inflammation, and deposits on the posterior sur-
face in connection with iritis. Those of the vitreous
indicate inflammation of the choroid or ciliary process, as
do also those of the lens, in some cases.
Crystals of cholesterin may be encountered in the cor-
nea, aqueous, lens, vitreous, or retina. They may appear
as flakes of opacity, or when the light strikes them at a
certain angle show brilliant iridescence. They are not
incompatible with normal vision, although more commonly
seen in the eyes that have undergone degenerative changes.
84 EXAMINATION OF THE EYE-GROUND.
EXAMINATION OF THE EYE-GROUND.
The Optic Disk. — Having searched the dioptric
media for opacities, the ophthalmoscopic examination is
directed to the region of the optic disk. The optic nerve
enters 10 or 12 degrees to the nasal side of the posterior
pole of the eyeball. To examine it the patient should
turn his eyes slightly toward the surgeon, who, keeping
still 10 degrees or 12 degrees to the temporal side of the
visual axis, is able to look in the direction of the optic
disk without getting in front of the patient's face. To
find the direction of the disk the surgeon watches the
fundus reflex, and moves his eye until the red glare from
the pupil becomes noticeably brighter and of a lighter
color, indicating that the optic disk has been brought in
line with it. Keeping as near as possible in this direc-
tion, the surgeon brings his own eye with the ophthalmo-
scope as close as possible to that of the patient, as shown
in Fig. 26. During this movement care must be taken
to keep the mirror so turned that it will steadily reflect
light into the patient's pupil — a thing difficult at first,
although easily done after long practice.
It is not sufficient for some part of the light from the
mirror to fall upon the patient's pupil. The light mus*
enter the patient's eye from the part of the mirror im-
mediately around the sight-hole. The form of tilting-
mirror illustrated in Fig. 25, the one commonly used on
American ophthalmoscopes, is much larger than is of
value for the direct ophthalmoscopic examination, in
which only a circle about 15 mm. in diameter immediately
around the sight-hole can be utilized. Light may fall on
the eye from other parts of the mirror without giving the
surgeon any fundus reflex whatever.
With the mirror properly directed and the surgeon's eye
as close as possible to that of the patient — generally within
one or two inches — there will appear in the pupil an area
of light color, surrounded by the darker red of the fundus
reflex. By relaxing the accommodation or pushing up
the proper lens, the margin of this area with the other
OPHTHALMOSCOPIC DIAGNOSIS.
85
details of the fundus will become clear. It is then found
that the area is circular or somewhat oval, generally with
the long axis vertical, and presents somewhat the appear-
ance shown in Fig. 28 and in Figs. 1, 3, 4, and 5 of the
colored plates I and II.
Its color is usually rather pink or cream, yet in contrast
with the darker red around, it looks almost white. In
some eyes it is quite gray, or even brown pigment
is deposited in its connective-tissue stroma. Striking
FIG. 28. — The normal fundus. The darker vessels are veins, the lighter
arteries. The dark specks on the oval optic disk are spaces in the lamina crib-
rosa. The light crescentic spot represents the reflex from the fovea.
anomalies are occasionally encountered. The common
variations of color, however, depend on the vascularity of
the nerve-head. It is generally darker on the nasal side
and paler at the center of the disk and toward the tem-
poral margin. At the border of the disk may be seen
points, or a complete ring of brown or black, the " chor-
oidal ring" (see Plates I and II). Within this may often be
86 EXAMINATION OF THE EYE-GROUND.
noticed a crescent to the temporal side (Plate II, 3), or a
complete ring of white surrounding the disk (Plate II, 4),
the part of the sclera exposed by a comparatively large
opening in the choroid.
Upon the disk appear as red lines, the retinal vessels,
the veins darker and more crimson in color, the arteries
lighter and more scarlet. The larger vessels show a
white glistening line along their centers — the light streak.
The smaller arteries and veins are more alike, so that
whether a certain vessel is an artery or a vein can only be
ascertained by noticing the larger vessel with which it is
connected. Frequently the normal veins may be seen to
pulsate where they turn to pass back into the optic nerve,
but pulsation of the arteries is abnormal. The largest
branches pass upward and downward, then bend toward
the temporal side.* Occasionally a vessel of medium size
does not arise from the general system of vessels upon the
disk, but appears independently near the temporal margin,
passes a little on to the disk, and then turns back and is
distributed to the retina toward the macula. Such are
called cilioretinal vessels (Plate -II, 1).
In the lighter area at the center of the disk may
often be seen a dark stippling, a network of white
with dark interspaces (See Plate II, 4 and 6, and
Fig. 28). This network is the lamina cribrosa, the
continuation of the sclerotic across the space through
which the optic nerve enters the eye, the white network
being the connective-tissue bundles, and the dark inter-
spaces the openings through which the nerve-fibers pass.
The center of the optic disk is commonly marked by a
depression — the physiological cup — which varies greatly
in depth and form in normal eyes. Its presence and
depth are most clearly demonstrated by measuring the
refraction of different portions of the disk-surface. Gen-
erally it is somewhat conical in shape. Compare Plate
I, 1, Plate II, 3 and 4, and Figs. 28, 29, 33, and 34.
Usually the nasal side is more abrupt than the tem-
poral. The central artery and the central vein, or their
primary branches, first make their appearance at the bot-
OPHTHALMOSCOPIC DIAGNOSIS. 87
torn of this cup, then pass up its sides or even into the
nerve-tissue around it, and emerge on the level of the
disk. Usually the diameter of the "physiological cup"
approaches half that of the optic disk ; but it may be
larger or smaller than this, or the cup may be entirely
absent without indicating disease.
The normal color of the fundus, or eye-ground,
varies greatly. The retina, which is almost transparent,
is only seen when the tissue behind it is of comparatively
dark color. The pigment-layer of the retina presents all
variations from complete transparency to almost complete
opacity, according to the amount of pigment deposited in
the cells. When transparent the color of the fundus is
the color of the structures behind it ; when opaque, noth-
ing back of this layer is visible. The fundus is compara-
tively dark in the dark races, brown, or mahogany,
rather than red. With such a background, the retina
will be noticed as a gray veil, thickest above and below
the optic disk, where it is somewhat striated, the striae
running in the direction of the bundles of nerve-fibers,
first upward and downward, and then curving around
above and below the region of the macula. The retinal
veil becomes thinner as we go forward toward the periph-
ery of the retina, until it is no longer visible.
When less pigment is deposited in the retinal pigment-
layer, more of a red glow is transmitted from the choroid
behind it, and with the increase of light coming through
it, the retina itself becomes less visible, and details of the
choroid may be seen. In most eyes, immediately around
the disk and in the macula, the retinal layer holds so
much pigment that none of the choroidal details are
visible, but toward the periphery of the fundus they may
be studied in nearly all eyes.
The details of the choroid consist first of the larg-
est choroidal vessels, which appear with interspaces, either
darker or lighter, according to the amount of pigment
deposited in the stroma of the choroid (see Fig. 118). The
vessels are comparatively broad, and form an irregular net-
work of rounded loops in contrast to the retinal vessels,
88 DETAILS OF THE CHOROID.
which are narrow and run a comparatively direct course
without inosculation, and bifurcate at irregular intervals,
the branches becoming progressively smaller toward the
periphery of the retina.
In most eyes the retinal vessels are the more distinctly
seen ; but in eyes devoid of pigment choroidal vessels
may appear equally distinct, so that only their size and
form of distribution reveal to which system they belong.
With diminution of pigment the fundtis becomes
lighter. In some albino eyes the general background is
a pink or yellowish white; against this background
appear many large and small vessels, among which it
becomes difficult to trace those belonging to the retina.
This general background is the sclera, revealed by the
transparency of 4>e coats in front of it, when these are
devoid of pigment.
The region of the macula is brought under inspec-
tion by having the patient look at the sight-hole in the
mirror. This brings the corneal reflex a good deal in
front of the pupil, and the greater sensitiveness of the
retina at this point causes the pupil to contract, so that
without the use of a mydriatic it is sometimes impossible
to make a thorough examination of this region. What-
ever the general pigmentation of the eye, it is greatest in
the region of the macula, where the vessels of the choroid
are rarely traceable.
The greater thickness of the retina in this region with
this darker background causes it to be more frequently
visible here than in other parts of the eye, except above
and below the optic disk. The distribution of retinal
vessels in this region is peculiar ; the principal trunks run
above and below the macula, only as a rare anomaly
crossing it. These trunks give off branches which run
directly toward the macula from all sides, and become
invisible by division. In the macula the only detail to
be recognized is the granular appearance due to the
irregular distribution of pigment in the retinal pigment-
layer. This granular appearance exists throughout the
eye, being most noticeable in eyes of moderate or dark
OPHTHALMOSCOPIG DIAGNOSIS. 89
pigmentation, but it is best developed in this region of
the macula.
At the center of the macula is commonly found a cres-
cent of shining reflex, marking the border of the fovea
centralis (see Fig. 28). It varies in size and shape with the
vary ing dimensions of that depression in the retina, the cres-
cent being a reflection from a portion of the margin of the
depression. By slightly changing the angle at which the
light enters the eye, by change of the direction of the
mirror, the part from which the reflection is obtained
varies ; sometimes the complete ring of reflex may be
seen.
Retinal Reflections. — Gleams of light, shifting or
vanishing as the position or direction of the mirror is
slightly changed, may be perceived in various parts of
the retina. In an eye with a dark retina and choroid
these often resemble the reflections from the surface of
silk, and are spoken of as the " watered silk" or "shotted
silk " appearance of the retina. Sometimes they follow
the course of the largest retinal vessels, but often they
cross them irregularly. They are best studied with a
mirror having a very short focus, and with a lens focussed
for rays coming from a little in front of the retina.
With the ordinary ophthalmoscope mirror they are more
noticeable through the undilated pupil than after the use
of a mydriatic.
One of the most regular of these reflections is an oval,
or sometimes circle, around the macula (see Plate I, 1).
Through the undilated pupil usually only small portions
of this can be seen at once, and after the use of a mydri-
atic it often cannot be discovered, except with a special
mirror. Increased visibility of these reflections has been
regarded as an evidence of irritation or edema of the retina,
but it must be considered a rather indefinite and uncertain
sign of such conditions.
A distinct reflex concentric with the optic disk and a
little to its nasal side, the " Weiss reflex," indicates swell-
ing of the disk, and has been considered an evidence of
progressive myopia. It is represented in Fig. 34.
90 ABNORMAL APPEARANCES OF THE RETINA.
ABNORMAL APPEARANCES AND ANOMALIES OF THE
RETINA.
Haziness in the retina interferes with the percep-
tion of the structures that lie back of it, as the stippling
of the pigment-layer, or the network of choroidal ves,-<'l.s
and also the parts of the retinal vessels that are deeply
buried in the retina. Where the vessels come close to>
or lie upon, the anterior surface of the retina, however,
they will be clearly seen, being often more distinct than
normal, because the gray of the hazy retina gives a
stronger contrast to the red of the vessel than does the
normal fund us.
Haziness in the retina renders more marked or extends
beyond the normal limits the appearance of the retina as
a gray veil. In,proportion as it is present, the red hue
of the fundus is masked by the gray or the green-
ish or bluish color that it causes. It may be either
general or localized. In the former case it is most
pronounced in those regions where the retina is thickest.
In general, it indicates edematous swelling of the retina.
Haziness of the retina is seen in some cases of eye-
strain. It is also likely to be present after bruise of the
eyeball, causing a general disturbance of the coats. It is
an early sign of albuminnric retinitis, one of the distinc-
tive signs of neuroretinitis, and is very marked in the
retinitis of leukemia. It is very pronounced and general
in embolism or thrombosis of the central retinal vessels,
sometimes giving the fundus of the eye a gray or white
appearance that shades off toward the periphery, and in
the macula is interrupted by a very dark red spot at the
fovea. (Compare Plate I*, 2, and Figs. 116, 117, and
119.)
Hemorrhage sometimes occurs on the surface of the
retina, immediately adjoining the hyaloid membrane
separating it from the vitreous. Such a hemorrhage may
be seen covering the region of the macula or in other
parts of the eye, having a sharply defined, rounded bor-
der. Such gubhyaloid hemorrhages are to be distinguished
from those occurring into the substance of the retina.
OPHTIIALMOSGOPIC DIAGNOSIS. 91
These latter generally lie in the nerve-fiber layer, and the
blood composing them is distributed somewhat in the
direction taken by the nerve-fibers. They have what is
called a " flame-shaped " outline, the narrower end toward
the optic disk and the broader extremity from it, with
feathered edges, especially at its peripheral margin (see
Plate I, 2, II, 8, and Figs. 116 and 117).
Such hemorrhages conceal the retinal vessels that pass
across them.
Fatty degeneration, either of the retina or of
exudate into it, causes a patch of white, often quite bril-
liant. Such white patches are especially characteristic of
the retinitis that attends chronic vascular and renal dis-
ease— albuminuric retinitis (Plate I, 2, and Fig. 117).
In this affection there are at the macula points or large
patches of white, arranged in lines radiating from the
center of the macula, sometimes in only one direction,
sometimes in all directions. The typical appearance is
seen before the spots run together in large irregular
patches, when the appearance is less characteristic. In
the later stages, too, the patches are less likely to be
pure white, but have a brownish discoloration. Some-
times the white patches of fatty degeneration are con-
fined to the walls of one or more vessels, causing the
vessel for a certain distance to appear as a white line
(Plate I, 1). Such an appearance indicates advanced
degeneration of the vessel-walls, generally attended with
similar changes in other vessels of the body. White
patches in the retina have to be distinguished from white
patches back of the retina, due to exposure of the sclera
through atrophy of intervening structures.
Mednllated Nerve-fibers. — In the optic nerve each
axis-cylinder has its opaque medullary sheath, but in the
retina the sheath is lacking. At or behind the lamina
cribrosa the sheath commonly begins. If it begins just
in front of the lamina the nerve-head is rendered opaque
and the lamina invisible. Sometimes a portion of the
nerve-fibers have medullary sheaths while in the retina.
When a very few fibers are thus furnished, there results a
92 MEDULLATED NERVE-FIBERS.
striate appearance of the retina, frequently seen above or
below the optic disk. When a large number of the fibers
are so covered, the result is a large white patch resem-
bling in color the patches of fatty degeneration in the
retina, but, unlike them, situated at the upper or lower
margin of the disk and extending in the direction in
which the nerve-fibers run (see Fig. 125).
In most cases of the kind the fibers do not keep the
sheath continuously, but lose it at the edge of the optic
disk, so that the white patch does not hide the disk itself
but is confined to the neighboring retina. Its distal mar-
gin is never abrupt, some of the fibers losing their sheaths,
while others still retain them, giving a gradual tran-
sition from the white patch to the normal red of the
fundus — the so-called " feathered edge." It is this edge
and the distribution of the white patch that distinguish
medullated nerve-fibers from the sharply bounded, white
patches of retinal degeneration. In both cases the retinal
vessels may run across the surface at some points, and at
others may be quite lost from view in the white opaque
tissue.
Changes in the Retinal Vessels. — Hyperemia
of the retina is not exhibited by an increase in the gen-
eral red of the fundus so much as by the enlargement of
the individual retinal vessels. By enlargement a greater
number become visible ; the principal branches are
noticeably broadened as compared with the size of the
optic disk; and the vessels, enlarged not only laterally but
also in the direction of their length, become more tortu-
ous. Their tortuosity is shown, both by their more visibly
wavy course and by the fact that certain portions of each
vessel stand out in front of the retina, while other parts are
correspondingly sunk beneath the surface. In the pres-
ence of haziness of the retina this makes a decided con-
trast in the clearness with which the different parts of a
vessel are seen. This symptom must be carefully distin-
guished from one of the ophthalmoscopic appearances of
astigmatism. (Compare the appearances represented in
OPHTHALMOSCOriC DIAGNOSIS. 93
Plate I, 2, and* in Plate II, 8 with the appearances of
these plates seen through a strong cylindrical lens.)
Enlargement of the retinal vessels is commonly
uniform unless the vessel-walls are themselves diseased,
when they are liable to irregular dilatations. In elderly
persons irregularities in the caliber of the retinal vessels
are not rare. It cannot be asserted that these vessels
are entirely healthy, although sometimes they seem to
return to and remain in a normal condition. Contraction
of the retinal vessels is mostly seen in connection with
optic atrophy. It indicates that the atrophy has been due
to disease involving the retina. It is commonly general
and uniform, except when arising from disease of the
vessel- walls, or shortly after a complete or almost com-
plete interruption of the retinal circulation, as by embol-
ism. The arteries and veins may be equally dilated or
contracted, or one set of vessels may be more altered than
the other. Pressure at the nerve-head, as in glaucoma
or optic neuritis, tends to distend the veins and diminish
the arteries (see Figs. 30 and 32). The color of the
retinal vessels may be altered by changes in the con-
stitution of the contained blood. In diabetes it is some-
times impossible to distinguish between the arteries and
veins. In anemia they become paler, especially the veins.
At death the blood-column is seen to become finely gran-
ular before its movement ceases.
CHANGES IN THE OPTIC DISK.
Redness. — Most of the eyes examined ophthalmos-
copically present disks that are abnormally red. Redness
of the disk is liable to attend all kinds of eye-strain and
all ocular inflammation. Within the normal limits, how-
ever, the redness of the disk varies greatly, and its
apparent redness depends also on the contrast of the color
of the fund us around it. When the fundus is dark, the
disk appears relatively white by contrast, and when the
surrounding fundus is light, the disk appears more nearly
of the same color.
94 CHANGES IN THE OPTIC DISK.
Only by the extensive use of the ophthalmoscope, in-
cluding examinations of normal eyes, can the observer
establish an approximate standard for the normal color
of the disk. Increased redness, if slight, does not hide
the usual gradations of colors presented by the normal
disk. The temporal side and central depression remain
less red than other parts ; but, if the hyperemia be very
great, these differences of color are usually less pro-
nounced. Redness of the disk includes a uniform altera-
tion of hue from dilatation of invisible vessels, and the
increase in size and number of visible vessels. At its
maximum the disk may have the color of the surrounding
fundus. The increased redness may be limited to the
disk in cases of optic neuritis. In cases of eye-strain,
however, it is associated with hyperemia of the retina and
choroid, more cWsely and directly with the latter, because
the vessels which supply the head of the optic nerve are
not branches of the central retinal vessels, but branches of
the vessels that furnish the blood-supply of the choroid.
The hyperemia of the disk arising from eye-strain is
essentially similar to the hyperemia present in the early
stage of serious organic disease of the optic nerve, in con-
nection with brain-tumor or meningitis. In later stages
of optic neuritis from brain-disease the hyperemia is quite
different. The general pink flush that exists in health
and is emphasized in early hyperemia is wanting ; and
the alteration of color depends on an increase in number,
with irregular dilatation of the smaller visible vessels.
Hyperemia of this character marks the transition from
inflammation of the optic nerve to atrophy.
Opacity of the Nerve-head. — The normal varia-
tions in the visibility of the lamina prevent it from serv-
ing as a test for the exudation in the nerve-head in a large
proportion of cases. If from previous examination it is
known that the lamina was normally visible, as in Fig. 29,
the obscuration of it will be one of the first signs of
opacity of the normally transparent tissue in the nerve-
head. Later may come obscuration of the large vessels,
the disk-margin, and the choroidal ring.
OPHTHALMOSCOPIC DIAGNOSIS.
95
The upper and lower margins of the disk are usually
partially obscured by the nerve-fibers, the bulk of which
pass off in these directions. Such obscuration is by
striations, while that due to swelling of the tissue is by a
general haziness.
The degree to which the different structures are ob-
scured will depend on the amount of exudation into the
nerve-head. In some cases it amounts to complete hid-
ing of the nerve-outline beneath a reddish-gray swelling,
which can only be certainly recognized as the site of the
i
FIG. 29.
FIG. 29.— The normal optic disk, shown in section below, in contrast with
FIG. 30, which shows the ophthalmoscopic appearances and section of the
optic nerve-head in optic neuritis.
optic disk by the divergence of the retinal vessels from
it (see Fig. 30). Such a condition is reached very
rarely in the neuritis, due to eye-strain. It indicates
rather that the changes in the nerve-head are due, either
to general disease, such as Bright's disease or pernicious
anemia, or to organic cerebral disease. In a very few
cases some such appearance may be presented as an
anomaly.
Swelling of the Disk. — Great opacity and hypere-
96 SWELLING OF THE DISK.
mia only occur with swelling. The swelling is shown by
the altered contour of the vessels, and particularly by the
difference of their refraction at the center of the cli^k,
from that of the neighboring fundus. This is to be
estimated with the ophthalmoscope by the method given
in Chapter VI. First, the refraction is to be measured
of the most prominent, most hyperopic, or least myopic
details of the nerve-head. Then the refraction of the
adjoining portion of the fundus which appears most
nearly normal is to be ascertained. The difference
between the two gives the height of the swelling.
It is to be borne in mind that in normal eyes there are
variations in refraction in different parts of the optic disk,
aside from the physiological cup. One may find a differ-
ence of one diopter or more between the temporal and
the nasal sides t»f the normal disk, the latter being usually
the more hyperopic. In some eyes, too, the nerve-head
normally projects in front of the surrounding fundus.
Redness, opacity, and swelling are signs of inflamma-
tion of the optic nerve-head, whether from eye-strain,
brain disease, or other causes.
Pallor of the Optic Disk. — The variations of the
color of the optic disk in health make it always difficult
to say when it is abnormally pale. The strictly normal
$isk is paler than the great majority of those examined.
Paleness of the disk indicates optic atrophy, and some-
times other signs of atrophy must be sought to decide if
the disk is abnormally pale. The slightest pallor of the
disk is a diminution of the pink blush, from narrowing of
invisible vessels. With greater change the number of
small visible vessels will be found reduced. In severe
cases, all of the small vessels become invisible, and only
the larger branches of the central retinal vessels can be
seen.
These retinal vessels may either remain of normal size,
as in primary optic atrophy or atrophy from disease of
the optic tracts, as illustrated in Fig. 31 ; they may be
somewhat enlarged, as in the earliest stages of postneuritic
atrophy ; or they may be diminished, as usually in the
OPHTHALMOSCOPIC DIAGNOSIS.
97
later stages of postneuritic atrophy, and in optic atrophy
due to diseases of the disk, retina, or choroid, or of the
vessels themselves (see Plate II, 9).
The color of the optic, disk does not depend solely upon
its blood-supply. In some cases of optic atrophy the disk
is dead white, in others more distinctly gray, bluish, or
even decidedly greenish, as seen by a yellow light. These
variations depend on the original color of the disk, and
on the amount and character of the exudation into the
nerve-head, during the process that has preceded the
atrophy (see Plate II, 9 and 10).
Cupping of the Disk. — Variations in the normal
level of the disk-surface and in the size and shape of the
physiological cup (Fig. 29) make it always difficult to
determine the beginning of pathological cupping of the
disk. The most constant distinction between the normal
FIG. 31.
FIG. 32.
FIG. 31 shows disk in optic atrophy with broader shallow depression than
in Fig. 29, and in contrast with FIG. 32, which shows the ophthalmoscopic
appearances and section of the glaucoiriatous excavation.
and the pathological cup is that the latter extends to the
disk-Tnargin, while the former does not. But in cases of
early glaucoma or atrophy, the cupping may not yet have
7
98 CUPPING OF THE OPTIC DISK.
reached quite 'to the margin, and in rare cases the cup
extends to the disk-margin, although vision and the visual
field are normal.
A broad shallow depression with sloping sides, saucer-
shaped (see Fig. 31), is to be regarded as due to paivnrliv-
matous or interstitial changes in the nerve-head. A cup
with abrupt edges, sometimes overhanging, as illustrated
in Fig. 32, is to be regarded as due to intra-ocular press-
ure ; generally to abnormally high intra-ocular tension —
glaucoma.
The existence and the extent of the cup of optic atrophy
are ascertained by the measurement of refraction at its
center and margins. The glaucoma cup presents a more
striking appearance. The retinal vessels appear at the
bottom of it, pass on to the sides of the cup, often entirely
out of sight, ancfr climbing over the margin of the cup,
reappear in a new position quite disconnected, apparently,
from the one they occupied at the bottom of the cup.
They therefore seem to have a new, hook-like beginning
at the disk-margin, the hook being the curve of the vessel
out of the cup to the general surface of the fundus. These
hooks, presenting a greater depth of blood to be looked
through, appear darker than the other parts of the vessels.
The normal optic nerve as it enters the sclerotic becomes
smaller, each nerve-fiber losing its medullary sheath.
On this account when the cup extends quite to the nerve-
margin, it is larger below the surface of the choroid than
at that point. It is what is called " kettle-shaped," so
that its margins overhang. The optic nerve enters the
eye from the nasal side and faces the center of the eye-
ball, not the pupil. Hence, without any overhanging
the nasal side of the cup would be invisible, while the
temporal side would still be seen.
The depth of the pathological cup is of little value for
prognosis. It depends largely upon the extent of the
physiological cup previously present, and in glaucoma
more on the duration of the process than on the malig-
nancy of the case.
Anomalies of the Optic Nerve.— Sometimes the
OPHTHALMOSCOPIC DIAGNOSIS. 99
site of the optic disk is occupied by a cavity which may
be broader and deeper than the largest glaucoma cup,
along the side of which the normal amount of nerve-tissue
may make its way to the retina, securing full vision and
a good field ; or nerve-tissue may be largely or entirely
absent, and the sight correspondingly defective. This
condition is known as coloboma of the optic nerve. The
visible cavity sometimes extends a considerable distance
back of the sclera and may vary greatly in size. It may
be associated with coloboma of the choroid or exist alone.
PIGMENTATION.
Pigmentation of the optic nerve is not rare. The
pigment appears as one or more black blotches, like an
irregular ink-spot on the disk. In rarer cases a pigmen-
tation, apparently continuous with that of the normal
choroid and pigment coat of the retina, seems to cover a
portion of the disk (see Plate II, 5).
Pigment-deposits in the General Fundus.—
These are dark brown or black in color, and of irregular
shapes. They must be distinguished from opacities in
the media. This is done easily enough when the eye is
steady, and they are clearly focussed, but it is sometimes
difficult when only glimpses of a dark object are caught
during ocular movements. They are located either in
the retina or choroid.
Pigment-deposits in the Retina. — In the retina
they sometimes overlie the branches of the retinal vessels
or enclose the vessel like a sheath. Sometimes the vessel
around or along which the pigment-patch is developed is
too small to be visible, or disappears in the course of
later degenerative changes, the pigment-spot retaining
the branched shape of the vessel. Other spots have the
form of a central lens-shaped body with radiating
branches, somewhat the shape of a " bone-corpuscle."
These are the typical forms of retinal pigment-deposits.
They are illustrated in Fig. 118.
A striking form of retinal pigment presents a large
100 PIGMENT DEPOSITS IN THE RETINA.
area or areas of black or very dark pigment, giving, at
first glance, the impression of very serious disease, but it
shows no disturbance of the choroidal tissue, and is com-
patible with full vision. Another anomaly consists of
dots of dark brown or black occurring singly or in groups
upon a background of normal fundus.
Choroidal Pigment-changes. — In the choroid the
patches of pigment are rounded or irregular in shape,
and associated with more or less choroidal atrophy. Their
most common seat is in the region immediately around
the disk. Normally, outside of the disk-margin is gener-
ally found a ring of pigmentation darker than that of the
general fundus, called choroidal ring (see Plates I and IT
and Fig. 31). This varies in width from a mere line to
one-third or one-half that of the disk. It is sometimes
uniform throughout, but more frequently broader in one
direction than in others. In the majority of eyes the
pigmentation of the ring is quite irregular. At some
points the pigment is heaped up in black masses ; at
others it is partly or entirely removed with more or
less complete atrophy of the choroid. While such irregu-
FIG. 33. FIG. 34.
FIG. 33.— Myopic crescent, early stage ; atrophy of choroid incomplete.
FIG. 34. — Myopic crescent more advanced. The atrophy of the original cres-
cent is now complete, and a larger crescent of incomplete atrophy has formed,
and a crescent of pigment-disturbance beyond that. The disk has also become
more oblique, and therefore, apparently narrower. On the right is seen the
curved reflex of Weiss.
larities may be normal, they denote in a large proportion
of cases, as in that represented in Fig. 33, past eye-strain,
with hyperemia of the part succeeded by atrophy. The
extension of the atrophy and the pushing before it of
OPHTHALMOSCOPIC DIAGNOSIS. 101
irregular pigmentation, usually to the temporal side of
the disk, give the atrophic crescent of myopia (see Figs.
33 and 34). Sometimes the area of this crescent is
entirely white or yellowish white, except where the
retinal vessels cross it ; in other cases it shows irregular
pigment-patches.
Pigment-blotches at the macula result from in-
flammation of the choroid, or perhaps hemorrhages.
Multiple patches of pigment-deposit with choroidal
atrophy, whether few or many, indicate disseminated
choroiditis (see Fig. 110). Where numerous, they are
frequently confluent, forming large areas. The pigment-
deposit marks a late stage of choroiditis. During the
early stages there is no increase of pigment ; and when
the deposit becomes entirely stationary, it is probable
that the morbid process has run its course, and that
no further change will occur.
Spots with rounded or oval outline, either discrete or
confluent, may be indicative of syphilis, but cannot be
regarded as pathognomonic. Sometimes choroidal changes
accompany the bone-corpuscle pigment-patches character-
istic of retinitis pigmentosa ; this association usually indi-
cates a form of disease due to acquired syphilis.
CHOROIDAL EXUDATE AND CHOROIDAL ATROPHY.
A light spot in the fundus is known to be due to lesions
lying back of the retina, when the retinal vessels pass
across it without being rendered less distinct, or when
choroidal vessels are seen in it. Yellowish or orange-
colored spots, generally slightly swollen, sometimes sur-
rounded by a darker red than is normal to the fundus,
indicate localized exudation into the choroid. Very acute
choroidal exudation is usually attended with considerable
haziness of the retina and vitreous in front of it ; where
the choroidal condition is not thus veiled, it is probably
somewhat chronic.
From the yellowish indefinite discoloration of the
choroidal exudation there is, with the progress of the
102 CHOROIDAL EXUDATE AND ATROPHY.
case, the gradual passing over into the whiter, but still
somewhat yellow, patch of atrophy. As the transition
occurs, the swelling disappears, and usually along the
margin of the spot pigment-deposits become evident.
Primary atrophy, or atrophy without swelling of the
choroid, leads first to a diminution of the fundus red;
then the larger choroidal vessels become visible. Later,
these too undergo contraction, and may also entirely dis-
appear. There remains then only the white area of sclera,
more or less discolored by pigment, over which may pass
the retinal or some of the largest choroidal vessels. As
compared with the color of the normal disk, complete
choroidal atrophy is decidedly whiter ; but it never pre-
sents the gleaming white appearance of medullated nerve-
fibers, or fiitty degeneration of the retina in albuminuric
retinitis.
The " Myopic " Crescent. — The commonest seat
of choroidal atrophy is to the temporal side of the disk,
where it may be seen in many cases of severe eye-strain,
being most largely developed in cases of progressive
myopia. Such an atrophy starts first as a yellow crescent
lying on the temporal side of the disk, which broadens
either by gradual extension, or by the successive appear-
ance of similar crescents of atrophy to the temporal side.
If these proceed far enough, there results a somewhat tri-
angular area of yellowish white, with its base at the disk
and its apex toward the macula, called a conus (see Fig.
63). With its extension in this direction the atrophy is
apt also to encircle the disk, and gradually extend in
other directions.
Other I/ocal I/esions. — Less frequently choroidal
exudate or atrophy is found in other parts of the fundus,
being most serious in the region of the macula, which
should be carefully searched .for them. Such areas may
also be found confined to the periphery of the fundus.
One or more crescentic areas, approximately concentric
with the optic disk, but quite removed from it, generally
in the direction of the macula, sometimes even beyond it,
are characteristic of so-called mpture of ike choroid (see
OPHTUALMOSCOPIC DIAGNOSIS.
103
Fig. 148). They are usually attended with marked altera-
tions of other parts of the fundus. Occasionally there
occur sharply defined, rounded areas, or a similar white
area stretches from some point below the disk or even
from above the disk forward to the lower periphery of
the fundus. This is coloboma of the choroid (see Fig.
34 a. 34 6.
FIGS. 34 a and 34 b. — Anomalous deposits of pigment in the choroidal ring.
115). Anomalies of the choroid, such as are shown in
Figs. 34 a and 34 b, and which are due simply to an
unusual formation of pigment, and not to any pathologi-
cal change, are generally to be known by absence of
atrophy in connection with the pigment deposit. (Com-
pare with Figs. 33 and 34.)
CHAPTER V.
REFRACTION; PRISMS AND LENSES, AND THEIR
STRENGTH AND NUMBERING.
UPON the free surface of the body light falls from each
point of every visible object, and were the sensitive
retina so placed as to receive this light, each point of the
retina would be impressed by light from every luminous
point before it. Each point of the retina would then
receive an impression similar to that made upon every
other point, giving only a general perception of light.
104
IMPORTANCE OF REFRACTION.
For complete vision each luminous point must make
its distinct impression on a single point of the retina, and
through it upon a single nerve-cell or group of nerve-
cells in the brain. To accomplish this, the light falling on
the retina must be assorted or focussed. To support the
retina so that it shall properly receive assorted light is the
/unction of the eyeball. The assorting is eifected in the
human eye by refraction, and the whole function of the
eyeball being to support and protect the retina so that it may
receive properly refracted rays, the refraction of the eye
is of primary importance in its physiology and pathology.
REFRACTION OF LIGHT.
Light consists of successive waves passing from each
luminous point iji all directions, like the waves which
arise when a stone is dropped in still water.
The direction of wave-movement is always perpendicular
to the wave-crest or wave-front.
Waves of light travel faster in some substances than in
others. Upon these two facts depend all the phenomena
of refraction.
In Fig. 35 the circles represent wave-fronts of light
from a luminous point, A. The radiating lines perpen-
dicular to the wave-fronts represent the directions in
FIG. 35.— Waves of light passing off from a luminous point, and rays along
which the light passes.
which the different parts of these wave-fronts are moving.
They are called " rays " of light. Close to the point from
REFRACTION OF LIGHT. 105
which the light emanates, the rays included in a given
space as CD will be very divergent. At a greater dis-
tance the rays included in this same space C' D' will be
less divergent. As the waves pass on, the included part
of a wave -front becomes more and more nearly straight,
and at an infinite distance the rays included in a certain
space would be parallel, and the parts of the wave-fronts
not circular but straight. Here we have only to consider
the rays and parts of the wave-fronts that enter the eye
through the pupil, usually from 3 to 6 mm. in diameter.
It is customary to speak of rays that come from 20 feet
and only diverge the width of the pupil as parallel rays.
This is not strictly correct; but it is convenient, and
unless otherwise stated, they will be so considered here.
Transparent substances are called dioptric media.
Of the dioptric media we have to consider, light moves
most rapidly through air. If we take the time it requires
for light to travel a given distance in air as 1, the times
required to travel the same distance in other transparent
substances are indicated as follows :
Water, the cornea, aqueous or vitreous humors, . . 1.33
The crystalline lens, 1.45
Crown glass, used for spectacles, 1.53 to 1.54
Hock crystal, "pebble," 1.56
Flint glass, 1.57 to 1.70
Diamond, 2.25 to 2.60
Such a number indicating the relative length of time
required for light to travel a unit of distance in a given
substance is its index of refraction.
When light passes from a substance having one index
of refraction into a substance having another index of
refraction, its rate of movement undergoes a change cor-
responding to the difference between the two. On account
of slower movement the successive waves will be closer
together in the medium having the higher index, and on
account of faster movement they will be farther apart in
the medium having the lower index of refraction. What
occurs when the wave-fronts correspond to the surface
106
RETARDING OF LIGHT WA VES.
separating the media and the rays fall perpendicular to
that surface, is shown in Fig. 36.
A
G
FIG. 36.— Waves of light passing from air into glass, retarded, but their
direction not altered.
Within the suVJstance G (glass) having the higher index,
the wave-fronts are closer together, but have the same
direction, and the rays perpendicular to them have the
same direction, as in the substance A (air). This is true
whether the waves be passing from A to G or from G
to A.
When the wave-fronts and rays strike obliquely the
B'
"P
FIG. 37.— Refraction of light when the waves pass obliquely from the air into
glass, illustrating the " law of the sines."
surface separating the dioptric media, the effect is different,
as illustrated in Fig. 37.
REFRACTION OF LIGHT. 107
When a wave-front travelling through air reaches the
position BB', a portion at B passes into the second
medium, which we will take as glass, and its movement
is immediately retarded, so that while B' travels to 6", B
only travels to C, a distance the reciprocal of the index
of refraction of the glass, ^ • The eifect of this is
that when the wave has reached C C', its direction has
essentially changed; since light moves along lines per-
pendicular to the wave-fronts, its movement will now be
in rays perpendicular to (7(7, making a decided angle
with the rays perpendicular to BB'. By passing ob-
liquely from one dioptric medium into the other, the
direction of the rays of light has been changed.
The same thing occurs if the light passes from the glass
into the air, the wave-front going from CC' to BB'. In
either case the direction of the ray is equally bent at the
surface separating the two media. But, in passing toward
the medium having the higher index, called the more
refracting, the ray is bent toward a perpendicular PP' of
the bounding surface ; and in passing toward the medium
with a lower index of refraction, called the less refracting
medium, the ray is bent from the perpendicular. The
amount of this bending depends on the difference of the
indexes of refraction and on the obliquity of the wave-
front to the bounding surface. The more the wave is
retarded by the glass or the farther the wave at B has to
travel in the glass while the part at B' is still in air, the
greater will be the change of direction.
If PP' be drawn perpendicular to the bounding surface
at jB, the angle ABP' between the perpendicular and AS,
the direction of the incident ray, is called the angle of
incidence; and CBP, the angle between the same per-
pendicular and the direction of the ray after it has been
refracted, is called the angle of refraction. The relation
of one of these angles to the other is illustrated in the
triangles BB'C and BCC', the angle B'BO being equal
to the angle of incidence, ABP' (because their sides are
mutually perpendicular), and the angle BC'C being equal
108 LAW OF THE SINES.
to the angle of refraction PBC (because their sides are
mutually perpendicular). But these two triangles BB'C'
and .6(7' (7 are right-angled triangles with a common side
BC', which may be taken as radius or 1, for both triangles.
By the common relation of the sides of a right-angled
triangle to the sine of the opposite angle we have
EG' : 1 : : B'C' : sin B'BC?, the angle of incidence.
BO : 1 : : BC : sin BC'C, the angle of refraction.
orB'a'.smB'BC': :BC : sin BC'C.
sin B'BO : sin BC'C: •.B'C': BC.
That is, the sine of the angle of refraction is to the sine
of the angle of incidence, as the index of refraction of the
substance from which the light passes is to the index of
J \J ± J
refraction of the Substance to which the light passes. This
is called the law of the sines ; and, as is shown above,
depends simply on the fact that light moves perpendicular
to its wave-fronts.
When light passes through a plate of glass with parallel
sides, if it enter the glass in such a way that the rays are
perpendicular to the surface, their direction will not be
changed either on entering or leaving the glass. The
whole wave-front entering the glass at the same time is
equally retarded, and keeps its original direction, merely
moving through the glass more slowly ; and on reaching
the other surface it all passes out at once, and has its move-
ment equally accelerated in all parts (see Fig. 36). If a
ray of light fall obliquely upon the surface of the glass,
it will be refracted toward the perpendicular on entering
the glass, but equally from the perpendicular on leaving
it if the two surfaces of the glass are parallel ; so that the
direction of the ray after leaving the glass is parallel to
its direction before entering it. This is shown in Fig.
38, the ray AB being refracted toward the perpendicular
on entering the glass at B, and being refracted from the
perpendicular on leaving the glass at C, so that the direc-
tion of CD will be parallel to AB.
When, however, light passes through a piece of glass,
REFRACTION OF LIGHT.
109
the sides of which are not parallel, but inclined toward
one another, the portion of each light- wave that has to
pass through the thicker part of the glass is more retarded
FIG. 38.— Refraction of light by a plate of glass with parallel sides. Direction
of waves and rays altered on entering the glass, and restored on passing out.
than the portions of the wave which pass through the
thinner portions of the glass ; and, on this account the
direction of the wave-fronts, and the direction of the rays
FIG. 39.— Refraction of light by a prism. Direction of waves and rays altered
on entering the prism, and still further altered on leaving it.
perpendicular to it, are permanently changed. This
change is illustrated in Fig. 39, in which the wave-fronts
are changed from their original direction on entering the
glass, and swung around still further on leaving it, CD
having an essentially different direction from AS. In all
cases the part of the wave-front which goes through the
thicker portion of the glass is more retarded, so that the
ray is bent toward that part of the glass.
110 PRISMS.
PRISMS.
A piece of glass bounded by plane surfaces which are
inclined toward each other is called a prism. The line
in which these plane surfaces intersect is the edge or apex
of the prism. The thickest portion is the base of the
prism. The angle between the two intersecting surfaces
is called the refracting angle of the prism.
From what has been demonstrated it is evident that
if light passes through a prism it will be turned toward
the base, and after leaving the prism will proceed as
though from A' (Fig. 39), more in the direction of the apex.
The refracting power of the prism (its ability to turn rays
of light from their original direction) depends first on the
index of refraction of the glass of which the prism is com-
posed as companed with that of the air around the prism.
This determines the retardation of the wave while in the
prism. Second, it depends on the shape of the prism,
which determines how much longer one part of a light-
wave is subjected to the retarding influence of the glass
than another part.
The higher the index of refraction of the prism and the
larger its refracting angle, the " stronger " the prism.
The effect of the prism also depends on its obliquity
to the light. If the light enters or leaves the prism
very obliquely, it acts as a. stronger prism. This can
be demonstrated thus : Take a weak prism from the
trial case, hold it so as to be nearly perpendicular to the
line of sight, and note the displacement it seems to cause
in a line, like a window-sash. Then rotate the -prism
about its base or apex, and note how the displacement in-
creases as the surfaces become oblique. The effect of a
prism also varies with the color of the light that it refracts.
A prism of a given strength refracts the blue and the
violet rays more than the red. The difference of effect of
the same prism on light of different colors, causes the dis-
persion of white light into the prismatic colors or spec-
trum. This power of dispersiort differs with different sub-
stances, but not in proportion to the index of refraction.
REFRACTION BY PRISMS. Ill
Dispersion is much less through the crown glass, ordin-
arily used for spectacles, than it is for the heavier, softer
" flint " glass, employed in some other optical instru-
ments.
Numbering of Prisms. — Formerly prisms were
numbered by the refracting angle — that is, a prism hav-
ing surfaces which met at an angle of 10 degrees was
called a No. 10 prism. This was its number whatever
the kind of glass from which it was made, so that prisms
having the same number would vary according to the
index of refraction of the glass of which they were com-
posed. In 1887 the writer suggested that they should
be numbered according to the effect they produce on the
light passing through them, according to their angle of
deviation.
FIG. 40.— The course of a ray (A B C D) refracted by a prism.
In Fig. 40 the ray A B passing through the prism is
turned, so that instead of continuing in the direction of
.Fit proceeds toward 7). The angle D E F is the angle
of deviation. For " crown " glass this is somewhat more
than half the refracting angle B R C, so that if the prism
were numbered by degrees of deviation, a given number
would indicate a prism of almost double strength of the
old system. It is, however, proposed instead of number-:
ing the prism by degrees of deviation it produces, to
number it by the centrads (Dennett) or prism diopters
(Prentice) of deviation that it produces. A centrad
being a deviation, the arc of which is yw.of the radius,
and the prism diopter a deviation, the tangent of which
is T(L- of the radius.
For the strength of prisms ordinarily used, these will
112
NUMBERING OF PRISMS.
be practically the same thing ; and numbered by either
centrads or prism diopters, the numbering corresponds
very closely to that of the old system, because the prism
with one degree of refracting angle causes very nearly
one centrad, or one prism diopter of deviation.
The exact relations of the two systems are shown in
the following table :
TABLE I. — Numbering of Prisms.
DEVIATIONS.
DEVIATIONS.
Centrads. Prism Diopters. Angle.
Centrads.
Prism Diopters. Angle.
1
1.
1.06
9
9.02
9.39
2
2.
2.12
10
10.03
10.39
3
3.
3.18
11
11.03
11.37
4
4.
4.23
12
12.04
12.34
5
5.
5.28
13
13.06
13.29
6
6.01
6.32
15
15.11
15.16
7
7.01
7.35
20
20.26
19.45
8
8.02
8.38
50
54.62
36.03
The 30 centrad prism is just thirty times as strong as
the 1 centrad prism. It will be noticed that no such
relation exists between the strength and the numbers of
the prisms by the old system.
The practical uses of ophthalmic prisms will be dis-
cussed in connection with spectacles (Chapter VII) and
anomalies of the ocular muscles (Chapter VIII).
LENSES.
A lens is a portion of a dioptric medium bounded by
one or more curved surfaces. In passing through plane
surfaces, plane light-waves retain their original form, and
the rays keep their original relation to one another. In
passing through curved surfaces, however, the light-waves
become curved, or their curves become altered, so that
the relation of the rays perpendicular to them is also
altered.
This is illustrated in Fig. 41. The portion of each
light-wave that strikes the lens first is retarded, the por-
LENSES. 113
tions remaining in the air get ahead of it, changing the
shape of the wave-front. Again, the part of the wave-
front getting out first gets ahead of the part still in the
glass, and the form of the wave is still farther changed.
FIG. 41.— Effect of convex lens on waves of light passing through it.
In a lens, like the one represented in Fig. 41, thickest at
the center, called a convex lens, the effect is to turn all
parts of the wave toward the center, and so to converge
it to a single point or focus.
With the opposite kind of lens, represented in Fig.
42, called a concave lens, thinnest at the center and
FIG. 42.— Effect of concave lens on waves of light passing through it.
thickest at the margins, the waves are most retarded at the
margins, present convex surfaces after passing through
the lens, and tend to spread out as though they had
114 FOCUSSING BY LENSES.
started from a certain point, or focus in front of the
lens.
It is obvious that, in the first case, all the rays of light
tend, after passing through the lens, to come together at
the focus, which is called a real focus. In the second
case, after passing through the lens they all diverge as
though they had started from the focus, which is called
a virtual focus.
Another way to understand a lens is to regard it as
made up of a double series of prisms, very weak at the
center of the lens and increasing in strength as we go
toward the margin (see Fig. 43). Near the center the
rays will be refracted as by a weak prism, and the rays
more removed from the center will be refracted as by
stronger and stronger prisms.
FIG. 43.— Refraction by a lens, resembling refraction by a scries of prisms
which grow stronger the farther removed from the optical center. •
At one point of every complete lens the two surfaces
are parallel. Rays passing through this point, as through
a plate of glass with parallel sides, continue their course
unrefracted. This point is called the optical center of the
lens. In a convex lens it is the thickest part of the lens ;
in a concave lens it is the thinnest part.
Varieties .of I/enses. — Convex and concave lenses
are made of the different forms represented in Fig. 44.
1 is called a plano-convex, one side being plane. 2 is a
double convex, both sides being convex. It is called bi-
convex when both sides are equally convex. 3 is a con-
cavo-convex, one side concave, the other more convex. 4 is
LENSES.
115
plano-concave, 5 is a double concave or bi-concave, 6 is
convexo-concave ; 3 and 6 are alsq called meniscus or j?m'-
scopic lenses. All that are thickest at the center have the
23 456
FIG. 44.— Different forms of convex and concave lenses.
effect of convex lenses, and all that are thinnest at the
center have the effect of concave lenses.
Strength of I/enseS. — A lens of a certain strength
causes a certain amount of change in the direction of rays
passing through it. If these rays are parallel when they
fall upon it, they are converged to a certain focus F by a
convex lens (Fig. 45), or diverged from a certain focus
by a concave lens (Fig. 46).
If rays diverge from the focus (Fig. 45) of a convex
lens, they will be rendered parallel by it. If rays were
converging (Fig. 46) toward the focus of a concave
FIG. 45.— Focussing of parallel rays
by a convex lens.
FIG. 46.— Concave lens dispersing rays
as though from its virtual focus.
lens they would be rendered parallel by it. The change
in the direction of the rays is the same whichever way
they pass through the lens.
If instead of falling upon the lens parallel, they reach
116 STRENGTH OF LENSES.
it somewhat divergent, the convex lens will converge
them to a focus farther away from it than its focus for
parallel rays, or the concave lens diverge them from a
focus nearer the lens than the focus for the parallel rays.
If they fall on the lens convergent, the convex lens will
converge them to a nearer focus, and the concave lens
will diverge them from a focus farther away. Thus, for
every point from or toward which the rays pass before
striking the lens there will be a corresponding focus to or
from which they will go after leaving it. In this way
every lens has an infinite number of foci, corresponding
to the different distances from which rays may come.
In order to compare the strengths of different lenses it
is necessary to take their focal distance for rays of the
same sort. For this purpose the focal distance of the
lens for parallel rays is taken, the focus for these rays
being called the principal focus and its distance from the
lens the principal focal distance.
If not otherwise indicated, when the focus of a lens is
spoken of, it will be understood that the principal focus
is referred to, and that its focal distance means principal
focal distance.
By the strength of a lens is meant its power of turning
rays from their original course. If this be great, the lens
is spoken of as strong ; if it be slight, the lens is icc<iL\
A strong lens will bring rays quickly to a focus ; a
weaker lens has its focus at a greater distance. The dis-
tance of the focus from the lens is the inverse or recip-
rocal of the strength of the lens. Representing the dis-
tance of the focus from the lens by F and the strength of
the lens by S,
F = - and S = -
S F
Numbering of Censes. — The Inch System. — The
first lenses used for ophthalmic purposes were numbered
according to the radius of curvature of the tool on which
they were ground, both surfaces having the same curva-
ture. With the glass commonly employed in them it
happened that for such a lens, the number indicating the
LENSES. 117
radius of curvature in inches also indicated approximately
the number of inches of the principal focal distance.
The radius of curvature was a tittle greater than the focal
distance. But most of the early trial-sets were made in
Paris and Berlin, and numbered according to Paris and
Berlin inches, which are slightly longer than the English
inch. Therefore, in English-speaking countries, the num-
ber of longer French or Prussian inches in the longer
radius of curvature almost exactly corresponded to the
number of shorter English inches in the shorter focal dis-
tance. The numbers, therefore, were soon generally re-
garded as indicating the focal distance of the lens.
In such a system of numbering the strength of the lens
was necessarily expressed by a fraction — one divided by
the focal distance of the lens. Thus, the 18-inch lens
had a strength of y1^. In combining lenses in practical
work, it becomes necessary to add and subtract the
strengths of the lenses combined. Such calculations
must be made repeatedly for every eye that is tested, and
the difficulty of adding and subtracting vulgar fractions
made it a matter of serious importance. Minor objec-
tions to the old system of numbering were the variations
of inches in different countries, and the irregular intervals
in the series.
To avoid these objections the dioptric or metric
system of numbering lenses was adopted. In it each
lens is numbered by its strength, in whole numbers or in
decimal fractions, which can be added or subtracted like
whole numbers. The unit is a diopter — the focussing power
required to bring parallel rays to a focus at a distance of
1 meter. A lens that has this focussing power is called a
1 diopter lens. A lens having twice this strength is
called the 2. D. lens, and has a focal distance of one-half
meter. One three times as strong is a 3. D. lens, and
has a focal distance of one-third meter. One having only
a quarter of the unit of strength is a 0.25 D. lens, and
has a focal distance of 4 meters ; and so on throughout
the series.
The greater convenience and uniformity of the dioptric
118 DIOPTRIC NUMBERING OF LENSES.
or metric system have caused its general adoption. It is,
however, well to be familiar with the old or inch system
of numbering, since in certain cases we have to add to, or
subtract from, the focal distance of a lens. In these
cases the old or inch system is much the more convenient,
because in it the focal distances are expressed in whole
numbers.
The equivalents for the metric lenses in ordinary use
are given in the following table. The first column gives
the metric number, the second gives the exact equivalent
focal distance .in inches, and the third column gives the
nearest equivalent commonly furnished in trial sets, or
spectacle lenses numbered according to the old system.
TABLE
II. — Numbering of
Lenses.
Strength,
Focal Distance,
Number in
Diopters.
Inches.
Old Series.
0.12 (0.125)
315.
0.25
157.5
144
0.37
105.
100
0.50
78.7
72
0.62
63.
60
0.75
52.5
48
0.87
45.
1.
39.37079
40
1.12
35.
36
1.25
31.5
30
1.37
28.6
1.50
26.2
24
1.75
22.5
2,
19.7
20
2.25
17.5
18
2.50
15.7
16
2.75
14.3
14
3.
13.1
3.25
12.1
12
3.50
11.2
11
3.75
10.5
4.
9.8
10
4.50
8.7
9
5.
7.9
8
5.50
7.2
7
6.
6.5
6
7.
5.6 '
5J
8.
4.9
5
9.
4.4
4*
LENSES. 119
Strength, Focal Distance, Number in
Diopters. Inches. Old Series.
10. 3.9 4
11. 3.6 3£
12. 3.3
13. 3. 3
14. 2.8 2f
15. 2.6 2£
16. 2.4
17. 2.3 2\
18. 2.2
19. 2.1
20. 2. 2
The Trial Set. — The lenses mentioned in the above
table are the spherical lenses, convex and concave, which
would be furnished in pairs in a complete trial set. In
addition the set should contain cylindrical lenses having
the same numbers up to 6. or 8. D., prisms of 1 to 20
centrads, a stenopaic slit, a pinhole disk, metal- and ground
glass disks, and two or more trial frames to support the
glasses before the eyes. Some of the weaker lenses may
be omitted, making the smallest interval 0.25 D. instead
of 0.12 D., without much impairing the practical useful-
ness of the set, even a very much smaller set will answer
the purpose. Thus by combining two or more lenses,
one can get all necessary powers from these few — 0.25,
0.50, 0.75, 1., 2., 3., 4., 5., 10., and 15. D. A larger
assortment is simply more convenient.
Use of Trial Lenses. — The lenses are used by placing
them before the patient's eye, to find by trial the lens or
combination of lenses with which he sees best. This
might be thought to require no special skill, and yet
accurate results with the trial lenses are not obtained
without care, system, experience, and good judgment.
If the testing is too long continued, the patient's atten-
tion is exhausted, and his answers become inaccurate and
unreliable. On this account it is always best to know
pretty nearly what his refraction is before starting with
the test lenses. Here is the great value of other methods
of measuring refraction. Then if the patient does tire
with the lenses, he should be allowed to go, and come
120 USE OF TRIAL LENSES.
again to have the test completed at another hour or on
another day.
To secure reliable answers the change made in the lens
should always be so great that the patient can certainly
notice an effect from it. Only when the vision is normal,
and the patient is a pretty good observer, can a 0.25 D.
of change be certainly recognized. Until vision has been
brought up to about the normal, the changes in the lenses
should be 0.50 D., or greater if the vision is very poor.
The change from one lens to another should be as
nearly instantaneous as possible. This is accomplished
by holding in the hand both the lenses that are to be com-
pared, and moving first one before the eye and then the
other in immediate succession ; or by placing one lens
in the trial frame and then holding before it a weak sup-
plementary lens* which, when added to the lens in the
trial frame, will make the desired change of strength.
The supplementary lens is held before the eye and then
removed, and this may be repeated several times, so that by
repeated trials the patient can make sure which is the better.
Often it is best to take two supplementary lenses in
the hand, one a weak convex, the other a weak concave,
and by trying first one and then the other, to ascertain if
it makes the vision better, to increase or to diminish the
strength of the lens before the eye. Thus, in a case in
which a + 2. D. lens seemed to be required, this should
be placed in the trial frame and a + 0.50 D. and a —
0.50 D. taken as supplementary lenses ; and held alter-
nately before the lens in the trial frame. The patient,
being asked which makes vision better, may say that the
— 0.50 D. makes it worse, but that he is uncertain if the
+ 0.50 D. really improves it. This would indicate that
+ 1.50 was worse than + 2., but that it was doubtful if
+ 2.50 were better than + 2. Hence, + 2.25 would prob-
ably prove the best correction. Here the doubling of a
change by reversal is utilized. When the change from 2.
to 2.50 did not make a very positive improvement, the
comparison of the 2.50 with 1.50 gave unmistakable
evidence in favor of the former.
REFRACTION OF LIGHT. 121
Fogging. — To bring out as much hyperopia as pos-
sible without a cycloplegic, the test at the first visit having
indicated certain lenses, at subsequent visits the pre-
viously determined correction, to which has been added
convex spherical 0.5 D. or 1 D., is placed before each
eye. This causes indistinctness of distant vision or " fog-
ging." The two eyes are then compared by alternately
covering first one and then the other; and if one shows
decidedly more blurring than its fellow, the convex spheri-
cal before it is reduced until vision in the two eyes is
about equal. Then the sphericals are reduced before
both eyes until the best vision is obtained. (For the use
of cylindrical lenses, see page 183.)
CHAPTER VI.
REFRACTION OF THE EYE; MYDRIATICS AND
MYOTICS; THE EEFRACTION OPHTHAL-
MOSCOPE; SKIASCOPY.
Assorting of I/ight. — If we take a convex lens, as
in Fig. 47, and suppose light to fall upon it from different
points, as A and B, from each of these points, one ray
will pass through the optical center, entering the lens and
emerging from it at points where its two surfaces are
D-
" a
FIG. 47.— Kays that pass through a lens without being refracted.
parallel. These rays will not be refracted, but pass on in
their original direction. All the other rays that fall upon
122 ASSORTING OF LIGHT.
the lens will be bent from their original course toward
the rays passing through the optical center. All the rays
from A being bent toward a, and all the rays from B
being bent toward some point b. The same tiling is true
of any number of points, the rays from C being collected at
c, and those from D at d. In this way all the light falling
on the lens is assorted, the light from each point in front
of the lens being collected at a single point behind it.
In the eye the convex surface of the cornea acts on the
light which enters it as a convex lens. Behind it is the
crystalline lens, acting as another convex lens. The
average normal cornea converges to a point 31 mm. behind
it, having a focussing power of 32 D. The crystalline
lens may be regarded as 6 mm. behind the cornea, where
the rays are converging toward a point 25 mm. away—
that is, they are "convergent to 40 D. The lens has a
converging affect of 20 D., which, added to the 40 D.,
makes 60 D. ; and after passing through the lens the rays
converge to a point 1000 •+• 60 = 16.667 mm. behind it, or
22.667 mm. behind the cornea, the point to which they
would converge if the cornea had a refracting power of
44 D. This is the dioptric eye.
The eye may be regarded as though the cornea and the
crystalline lens were replaced by a single stronger convex
lens situated at the cornea. Most of the optical problems
of the eye can be worked out more readily, and for all
practical purposes with equal exactness, with some such
reduced eye. The reduced eye of Donders has a cornea
with a radius of 5 mm., and the retina 20 mm. behind it.
In the eye the assorting of the rays is accomplished by
its focussing power. This is represented in Fig. 48. The
rays coming in a certain direction, as from the point A,
are focusses on a certain point a within the eye. The
rays entering the eye from the point B are focussed at
the point b. It will be noted that the rays are gradu-
ally concentrated, until a certain distance back from the
cornea, those coming from a single point outside of the
eye are brought to a single point within it. The assort-
ing of the rays is perfect only at this point. If the rays pass
REFRACTION OF THE EYE.
123
is
beyond ab they again spread out and intermingle. It
only at the one distance that the focussing is perfect, and
at this distance back of the cornea the retina must be
A
FIG. 48.— The focussing or assorting of light by the eye.
placed, if it is to receive perfectly focussed light, which
alone permits clear vision.
Refraction of the Bye. — We have seen, however,
that with any convex lens, the rays coming from points
at different distances in front of the lens will be focussed
at different distances behind it. It is, therefore, custom-
ary to speak of the refraction of the eye, as we do of the
refraction of a lens, with regard to its influence on
parallel rays.
An eye that is so proportioned that parallel rays will
be focussed on the retina as at E (that has the principal
focus of its dioptric media on its retina) is said to be
emmetropic. Its state of refraction is emmetropia. If
the retina be situated in front of the principal focus of
HEM
FIG. 49. — Position of retina in hyperopia, emmetropia, and myopia.
the dioptric media, as at H (parallel rays tending toward
a focus back of the retina), its refraction is hyperopia,
and the eye is hyperopic or hypermctropic. If the retina
is situated back of the focus of the dioptric media, as at
M (parallel rays being focussed in front of it), the refrac-
124 REFRACTION OF THE EYE.
tion of the eye is myopia, and the eye is myopic.
Emraetropia must be regarded as the standard of refraction
for the eye. All departures from this standard are in-
cluded under the general term ametropia. Such departures
from the standard of ocular refraction are spoken of as
errors or anomalies of refraction.
Accommodation. — To get distinct focussing of rays
having different degrees of divergence the eye has the
power of varying its lens-strength — the power of accom-
modation.
The refraction of the eye means its optical condition
with reference to parallel rays when it is entirely at rest.
This optical condition is independent of any muscular
exertion, and remains the same immediately after death,
or when all power of accommodation is removed, as by
the use of a mydfiatic. In this condition its refraction is
FIG. 50.— Change in lens during accommodation : Solid lines slipwlng outline
with A, relaxed ; broken line outline of lens during accommodation.
at its weakest. The power of accommodation is the
power to increase the refractive effect of the eye, by
increasing the curvature of the crystalline lens. This
increase of curvature is brought about by the natural
elasticity of the crystalline lens, which causes it to assume
a more convex form, when it is released from the tension
of the anterior and posterior layers of its capsule, between
which it is usually somewhat compressed and flattened.
The increased convexity of the lens occurs chiefly near
its anterior and posterior poles. The change of shape
REFRACTION OF THE EYE. 125
consists not in the lens becoming more globular, but in
the development of an anterior and a posterior lenticonus.
(See Fig. 50.) Accommodation is rendered more effective
by the accompanying contracted pupil, which admits
light only through the more convex center of the lens.
In any case it is certain that accommodation depends
on two factors — the active contraction of the ciliary
muscle, and the flexibility and elasticity of the lens.
In early childhood the lens is most flexible and elastic.
Year by year it becomes less flexible, and loses its elas-
ticity ; until, at about sixty or seventy years of age, it
becomes so rigid that it can undergo no change of shape
under the influence of the ciliary muscle. The loss of
elasticity causes loss of power of accommodation, which
goes on until at the age mentioned that power is usually
FIG. 51.— Effect of accommodation in focussing rays from a near point.
completely lost. Later the ciliary muscle undergoes
atrophy.
Pseudo-accommodation. — Occasionally after the re-
moval of the crystalline lens the patient is able to see
well through the same lens at different distances. This
may be due to the smallness of the pupil ; to differences
in refraction in different parts of the pupil ; to looking
obliquely through the lens, or by varying the distance of
the lens from the eye.
Effect of Accommodation. — This may be better
understood by study of Fig. 51, representing an emme-
tropic eye. The parallel rays coming from distant objects
are focussed on the retina ; but rays coming from a near
point P would, with the eye at rest, focus back of the
retina at p. By increasing the convexity of the lens to
just the proper extent, the focus of the dioptric system of
126 ACCOMMODATION.
the eye is shortened, so that for these diverging rays it
falls upon the retina at r.
The extent of change in the shape of the lens varies
with the contraction of the ciliary muscle, and can by it
be adjusted to rays of various degrees of divergence. The
variation of refractive power of which a given eye is cap-
able begins on the one side at the refraction of the eye
when entirely at rest, and extends on the other side to
that produced by the maximum contraction of which the
ciliary muscle in that particular eye is capable. When
this maximum power is exerted, rays of a certain degree
of divergence can be focussed on the retina. The point
from which come the rays that can just be focussed is
called the near point (punctum proximum) of distinct
vision. Paralysis of A. is considered, p. 333.
The difference«in refractive power between the dioptric
system of the eye with the ciliary muscle entirely at rest
and that of the eye with the ciliary muscle most strongly
contracted is called the amplitude of accommodation. It
is equal to the effect of a convex lens of a certain strength,
and is usually expressed as we express lens-strength, in
diopters. Thus, in an eye which when at rest focusses
parallel rays upon the retina, and which has a near point
of ^ of a meter, from which the rays reach the eye so
divergent that it would take an 8. D. lens to make them
parallel, the power of accommodation is said to be 8. D.
The following table gives the average power of accom-
modation in diopters, at different ages, with the distance
of the near point in inches, from an emmetropic eye hav-
ing such power of accommodation.
TABLE III. — Accommodation.
A, Pp.
Age. Diopters. Inches.
10 12.2 3.3
15 11. 3.7
20 10. 4.
25 9. 4.4
30 ........ 8. 4.9
35 7. 5.6
A. Pp.
Age. Diopters. Inches.
40 5.5 7.1
45 4.5 8.7
50 2.9 13.5
.V) 1.5 26.5
60 0.7 .5
65 0 0.0
MYDRIATICS AND MYOTICS. 127
MYDRIATICS OR CYCLOPLEQICS, AND MYOTICS.
Drugs like atropin, which are known as mydriatics,
on account of the dilatation of the pupil they produce,
have also the more important action of producing cyclo-
plegia, or paralysis of the ciliary muscle. These drugs
are as follows : Atropin is commonly used for its cyclo-
plegic effect in a solution of 1 to 120, 4 grains to the fluid
ounce. A single drop of this solution in the normal eye
will usually produce complete mydriasis and cycloplegia ;
but if it is entrusted to the patient or a member of his
family for application, it should be instilled three times a
day. The effect of such an application begins in fifteen
minutes, and reaches its maximum in two or three hours,
continues for two or three days with very little alteration,
and gradually passes off in two weeks.
Daturin, hyoscyamin, duboisin, and seopolamin are used
in solutions half or less than half the strength of that of
atropin. Their effect is similar, but begins in eight or
ten minutes, reaches a maximum in one or two hours, and
passes off in a week or ten days. Seopolamin is some-
times used in one-tenth of 1 per cent, solution, instilled two
or three times ; and in this way proves an efficient cyclo-
plegic, rather more brief in its action than when used in
stronger solution.
Homatropin is used in 2 or 3 per cent, solution, 10 or
15 grains to the fluid ounce, and even in that strength
must be used four or five times at intervals of five min-
utes, to produce full cycloplegia. It begins to act in fif-
teen minutes, reaches its maximum influence in one hour,
and passes off in about two days.
All of these drugs are liable in the doses mentioned to
cause constitutional symptoms, but homatropin causes
them very rarely and less severely than any of the others.
On this account, and because of the brevity of its action,
it is Jfi be preferred to other cycloplegics for diagnostic
purposes.
The use of one of these drugs is necessary, whenever
it is desired to make a complete study and accurate meas-
128 MYDRIATICS.
urement of the refraction, in a patient under fifty years
of age. Without them the refraction can be guessed at,
often correctly. Many patients have all their hyperopia
manifest, even in early life ; and in most eyes prolonged
and careful study, by all the objective and subjective
methods, will reveal approximately the astigmatism. But
without a cycloplegic, one cannot be certain of his ground,
he will generally be less accurate in his refraction work,
and in occasional cases he will make the most serious
blunders. Since patients usually come to a doctor for
glasses because they want certainty, as opposed to the
guessing of the optician, and since no serious inconvenience
is entailed, and the strained eyes are benefited by the use
of homatropin or one of the slower cycloplegics, they
should generally be used in studying the refraction of the
eye up to the age of fifty. Let it be remembered that
accommodation fails first from increasing rigidity of the
lens, and not from weakness of the ciliary muscle.
Hence about as strong a cycloplegic is required to paralyze
the accommodation at forty as in childhood.
When symptoms of mydriatic intoxication do arise —
usually unsteadiness of gait, or in children a pleased
delirium — the instillation of the drug should be stopped,
morphin administered in small doses, and water given
freely to favor elimination. Although a small dose of
one of these drugs may cause symptoms that will alarm
those about the patient, the dangerous dose is niuch larger
than the quantity commonly used as a cycloplegic.
After the age when accommodation ceases to interfere
with the measurement of refraction, it is sometimes neces-
sary to use a mydriatic simply to enlarge the pupil, as the
extreme contraction of the pupil sometimes found in
elderly people prevents the satisfactory examination of
the fundus or the accurate measurement of the refraction.
To overcome such contraction of the pupil a solution of
cocain 2 to 4 per cent., or the homatropin and cocain
solution may be used. These will require from thirty to
fifty minutes to dilate the pupil. They do not prevent its
contraction in strong light, avoiding much of the dazzling
MYDRIATICS OR CYCLOPLEGICS, AND MYOTICS. 129
caused by the other mydriatics, yet in a dark room or in
a moderate light they dilate the pupil more widely than
do the " stronger " mydriatics, and the effect passes off in
about twelve hours.
Euphthalmin, a true mydriatic more feeble and brief in
its action than homatropin, is a valuable dilator of the
pupil for diagnostic purposes, but has no practical value
as a cycloplegic. It is used in a 2 to 5 per cent, solution
of the hydrochlorate, or a solution of 1 per cent, each of
euphthalmin and cocain hydrochlorates.
The myotics are drugs which produce myosis — con-
traction of the pupil — and also cause increased contraction
of the ciliary muscle. In these respects they are direct
antagonists of the mydriatics ; but in other ways, as in
their influence on the nutrition of the cornea, they have
an effect quite similar to that of atropin.
Eserin, or Physostigmin. — A single drop of a solution of
the sulphate 1 to 2000, \ grain to the fluid ounce, in the
normal eye will produce a marked contraction of the
pupil, and increase the power of accommodation, and in
sensitive eyes causes painful spasm of the sphincter of the
pupil and of the ciliary muscle, with dimness of vision.
Shortly after its instillation there is generally a twitching
of the lids, which lasts ten or fifteen minutes. In fifteen
minutes the effect on the pupil is noticeable. The effect
reaches the maximum in one or two hours, and passes off
entirely in thirty-six to forty-eight hours. In old people,
in whom the ciliary muscle is atrophied and the pupil
sluggish, eserin is less likely to produce a painful spasm,
and can be used more freely.
Pilocarpin is commonly employed as a hydrochlorate.
It is twenty to twenty-five times weaker than eserin, and
not liable to cause painful spasm in the iris or ciliary
muscle. A drop of a solution 1 to 500 (gr. to f % j) pro-
duces contraction of the pupil and increase of accommo-
dation, beginning in twenty to thirty minutes, reaching a
maximum in one or two hours, and passing off in eight to
twelve hours.
130 MYOTICS.
For details regarding the practical use of mydriatics
and myotics see Chapter XVIII.
OPTICAL THEORY OF THE OPHTHALMOSCOPE.
Since the eye is able to focus the rays from a point out-
side of it to a single point on its retina, and since the
dioptric media exert the same influence on the light
emerging from the eye as upon the light entering it, the
rays from any particular point of the retina that pass out
through the pupil will all be turned toward a certain
point outside of the eye. Hence, on looking into an eye,
only those rays can reach the observer which come from
a certain part of the retina. In Fig. 48 (p. 123), looking
into the eye from A, only rays will be received that come
from a. But tire retina at a receives rays only from the
direction of A. Hence, when an observer's eye is placed
at A and shuts off, as it necessarily does, a considerable
amount of light from entering the observed eye in this
direction, the part of the retina at a is in shadow. Al-
though the retina at b may be brightly illuminated, all
the light from 6 passes to B, and so of all points of the
interior of the eye. The pupil of the observed eye, there-
fore, appears black. In looking into the eye under ordi-
nary conditions, although other parts of the retina may
be brilliantly lighted up, the part of the retina that the
observer sees is always in shadow.
To overcome this, and light up the part of the retina
looked at, the ophthalmoscope was devised. It enables
one to examine the interior of the eye by throwing light
from the mirror on the part of the retina looked at.
The mirror commonly used is concave. It converges
the light reflected from it, throwing a larger amount of
light into the pupil than would a plane mirror. This
light, being convergent, is generally focussed in front of
the retina, and forms on the retina a circle of diffused
light, favorable for revealing changes in the tissues ex-
amined. In eyes that are highly hyperopic the rays may
be focussed on the retina, in which case a small com-
REFRACTION OPHTHALMOSCOPE. 131
paratively distinct image of the lamp-flame is seen,
instead of the larger uniformly illuminated circle. The
mirrors employed on most American ophthalmoscopes
have a focussing distance of 6 or 8 inches, a sort of com-
promise between that which would be best for the direct,
and that which would be best for the indirect method of
examination. For the direct examination a mirror of
about 4 inches focal distance is most satisfactory. For
the indirect method one of 10 to 15 inches focal distance
is better.
If the ophthalmoscope is furnished with two mirrors,
the one for the direct examination should be small — 15
mm. in diameter — and should tilt. For the indirect
method of examination, the mirror need not tilt and may
be much larger, since whatever its size, light can be con-
centrated from all parts of it upon the pupil. The mirror
in ordinary use, shown in Fig. 25, is called the " rect-
angular tilting mirror." The size of the sight-hole in-
fluences the ease with which the instrument can be used
to inspect the fundus of the eye, and the accuracy with
which it will measure refraction. If the sight-hole be
small, it is comparatively easy to obtain a clear view of
the fundus, but the determination of the refraction will
be comparatively inexact. If the sight-hole be large, the
instrument will be more valuable to measure refraction, but
less perfectly suited to show the condition of the fundus
through an undilated pupil.
THE DIRECT METHOD FOR THE MEASUREMENT OF
REFRACTION.
Kmmetropia. — If the surgeon's eye be placed as close
as possible to the pupil of the patient's eye, it will receive
rays as they pass from the latter — parallel, divergent, or
convergent. If the surgeon's eye be emmetropic and his
accommodation relaxed, parallel rays will be accurately
focussed on his retina, as illustrated in Fig. 52, and a
clear view of the retina and choroid will be obtained.
Hyperopia. — If the patient's eye be hyperopic and
132 HYPEROPIA.
entirely at rest, the rays from his retina will diverge
on leaving the cornea; and, to render them parallel will
FIG. 52.— Course of the rays in emmetropia.
require such a convex lens as would cause parallel rays to
be focussed on the patient's retina. If this lens be placed
as represented by the solid lines in Fig. 53, it will
FIG. 53.— Course of the rays in hyperopia, patient's eye on the left. Dotted
lines show effect of accommodation in patient's eye ; broken lines show effect
of accommodation in the surgeon's eye.
render the divergent rays parallel ; they will be focussed
on the surgeon's retina, and the details of the fundus will
be clearly seen.
If the patient exerts any power of accommodation, the
rays emerge from his cornea less divergent, parallel, or
even convergent. In such a case the convex lens, other-
wise required, focusses the rays in front of the surgeon's
retina, and a blurred image results. Such a course of
the rays is illustrated by the dotted lines in Fig. 53.
Again, if the surgeon whose eye is emmetropic exerts his
own accommodation, he will no longer accurately focus
parallel rays, and will receive from them only a blurred
image. Such a course of the rays is shown by the broken
lines.
If accommodation is used during such an examination,
a weaker convex lens, or none at all, or even a concave
REFRACTION OPHTHALMOSCOPE. 133
lens will be required, and this is true whether the accom-
modation be in the patient's eye or in the surgeon's.
In myopia, as shown in Fig. 54, the rays from the
patient's retina emerge convergent; and without a lens
they would be focussed in front of the surgeon's retina,
FIG. 54. — Course of the rays in myopia. Dotted lines show A. in patient's eye ;
broken lines show A. in surgeon's eye.
giving only a blurred image. By placing before the eye
a concave lens just strong enough to correct the myopia,
these rays are rendered parallel, and the surgeon is able
to focus them on his retina. The use of any accommoda-
tion in this case, either in the patient's or in the surgeon's
eye, will again bring the rays to a focus in front of the
retina, illustrated as in the case of hyperopia by dotted
and broken lines, and will render necessary the employ-
ment of a concave lens stronger than is required to cor-
rect the myopia — one strong enough to correct the myopia
and neutralize the accommodation too.
Hence, the surgeon's eye being emmetropic, if no ac-
commodation be used, the lens that will give the clearest
view of the patient's fundus is the one that will correct
the ametropia.
If any accommodation be used, the strongest convex
lens, or the weakest concave lens, giving a clear view of
the fundus, will be the nearest right.
If the surgeon's eye be ametropic, he must use an addi-
tional lens to correct his ametropia, or must add or sub-
tract such correction to find the ametropia in the patient's
eye.
The measurement of refraction can be made with the
ophthalmoscope, with approximate accuracy, only after
long practice. The chief obstacle to accuracy is the exer-
134
MYOPIA.
tion of an unknown amount of accommodation. This
may be combated in the surgeon's eye by practice. Ac-
commodation in the patient's eye may be overcome by the
use of a cycloplegic. It may often be relaxed by making
the ophthalmoscopic examination in a large, thoroughly
darkened room, with the patient's gaze fixed on a perfectly
blank wall at the farther end. But the measurement of
refraction by the ophthalmoscope can never be relied on
for the accurate prescription of lenses. It is chiefly of
value for an approximate diagnosis, or to determine the
extent of swelling in the fundus, or the location of an
opacity in the vitreous.
The actual shortening or lengthening of the eye, cor-
responding to different degrees of hyperopia and myopia,
is shown by the following table :
TABLE IV. — Changes in the Visual Axis for Each D.
of Ametropia.
Diopters.
1 ....
H.,
Shorten-
ing.
. . .31
M.,
Lengthen-
ing.
.32
Diopters.
11 .
H.,
Shorten-
ing.
302
M.,
Lengthen-
ing.
426
2 ....
. . .62
.66
12
325
473
3 ....
. . 92
1.01
13
347
5 23
4 . . . .
5 ....
. . 1.21
. . 1.50
1.37
1.74
14 . . .
15 . .
. . 3.69
. 391
5.74
628
6 ....
. . 1.76
2.13
16 ...
. . 411
6 83
7 ....
8 ....
9 ....
. . 2.03
. . 2.28
. . 253
2.52
2.93
335
17 ...
18 ...
19
. . 4.32
. . 4.52
4 71
7.41
8.03
865
10 .
2.78
3.80
20
. 4.90
931
SKIASCOPY.
Myopia. — As already mentioned, rays from the retina
of the myopic eye pass into the air convergent. If not
interrupted in their course they continue to converge until
they are focussed at that point in front of the eye, for
which it is optically adjusted. This is true of rays com-
ing from each point of the retina, so that at that distance
there is formed an image of the fundus. This image is
inverted, as is illustrated in Fig. 55. The rays from the
SKIASCOPY. 135
lower part of the retina come to a focus above, and form
the upper part of the image, and the rays from the upper
part of the retina are focussed below to form the lower
part of the image. If the surgeon places his eye closer
than this image to the eye of the patient, as at A in Fig.
FIG. 55.— Focussing of rays coming from the retina in skiascopy; and the
point of reversal.
•
55, he will observe the fundus of the patient's eye in an
erect image, as he does in the direct method of ophthal-
moscopic examination. This image may require a con-
cave lens to render it clear ; but whether clear or dim, it
is necessarily erect. If the surgeon's eye be placed
farther from the patient's than £, as at C he will no
longer view the erect image, but will perceive the inverted
image formed in the air at B. This inverted image may
require the use of a convex lens to focus it clearly upon
the surgeon's retina ; but whether clearly focussed or not,
it is always an inverted image.
We have, therefore, at the point jB, for which the
myopic eye is optically adjusted, reversal of the image
seen ; this point we therefore name the point of reversal.
Its position is to be determined by noticing where the
erect changes into the inverted image, or vice versa.
Having ascertained its position, the measurement of its
distance from the patient's eye gives the focal distance of
the lens required to correct his myopia.
Details of the Test. — Skiascopy (the shadow-test
or retinoscopy) is a method of determining the position
of this point of reversal, by noting the apparent direction
of the movement of light and shadow across the
pupil. The movement of light and shadow in the pupil
136
DETAILS OF THE TEST.
is produced by changing the inclination of a perforated
mirror which reflects light into the eye.
The best light is furnished by acetylene gas, next comes
that of the incandescent mantle (Welsbach), or a good
candle ; but a gas or kerosene-flame will answer. The
mirror employed may be either plane or concave.
With the plane mirror the source of light is to lie
brought as close to the mirror as possible, and shaded
from the patient's face, as shown in Fig. 56, an opening
FIG. 56.— Position of light (L), mirror (Jlf), and eyes of surgeon (0) and patient
(P) for skiascopy with the plane mirror.
5 mm. in diameter being left in the shade opposite the
brightest part of the flame. The mirror should have a
central opening 2 to 2.5 mm. in diameter.
The effect of changing the inclination of the mirror is
represented in Fig. 57, in which light from the lamp-flame
FIG. 57.— Skiascopy with the plane mirror.
L is reflected into the eye from the mirror first held at
A A and then moved to B B. With the mirror at A A,
the light enters the eye as though it came from /, and
falls on the retina toward a. With the mirror at B B,
the light enters the eye as though it came from /', and it
SKIASCOPY. 137
falls in the direction of 6. As the mirror is moved from
A A to B B, the light moves on the retina from a to b.
At the same time the part of the light from the mirror
which falls on the face about the eye, moves upward —
that is, the light on the retina moves, " with " the light
on the face — " with " the mirror.
This happens whether the retina be situated at 'H, E,
or M ; whether the eye be hyperopic, emmetropic, or
myopic. With the plane mirror the real movement of
the light upon the retina is always " with " the movement
on the face. If the retina be seen in the erect image, the
apparent movement of the light in the pupil will be
" with " the light on the face. If the retina be seen with
the inverted image, the apparent movement of the light
in the pupil will be the opposite of the real move-
ment. Farther from the patient's eye than the point of
reversal, the light in the pupil, therefore, appears to move
" against " the light on the face.
With a concave mirror the movement of the light and
shade will be just the opposite of the above. Why this
is so is illustrated in Fig. 58. L, the lamp-flame, is placed
F^z
fr=
]4=— — *~^-
FIG. 58. — Skiascopy with the concave mirror.
behind the patient, the rays from it being focussed by the
concave mirror at I when the mirror is at A A, and at I '
when the mirror is at B B. From / they enter the eye
toward « on the upper part of the retina. From lf they
fall on the lower part of the retina toward b. When
the mirror is at A A, the light is thrown down on the
138 DETAILS OF THE TEST.
face, but falls on the upper part of the retina. When the
mirror is at B B the area of the light is higher on the
face, but lower upon the retina. Hence, with the con-
cave mirror the light on the retina really moves " against"
the mirror — "against" the light on the face.
The apparent movement of the light being watched in
the pupil, when the erect image is seen will be in the real
direction, and when seen in the inverted image, in the
opposite direction. Hence, in any case of myopia, testing
with the plane mirror will show the light moving " with "
the light on the face when viewed closer than the point
of reversal, and moving against the light on the face
when viewed from beyond the point of reversal. If
tested with a concave mirror, it will show the light in the
pupil moving " against" the light on the face from within
the point of reversal, and " with " the light on the face
beyond the point of reversal.
Distance. — In practice one should vary his distance so
as to try the movements both from within the point of
reversal and from beyond it, until the approximate posi-
tion of that point is determined with certainty. When
the plane mirror is used, the distance of the surgeon from
the patient can be varied greatly, without interfering
much with the accuracy of the test. With a concave
mirror, however, but very slight variations of distance
between the patient and the surgeon are admissible. It
is necessary to keep the surgeon's eye a fixed distance
from the patient's, and cause the distance of the point of
reversal to vary, by placing before the patient's eye lenses
that will correct more or less of the myopia. The distance
for the usual concave ophthalmoscopic mirror should be
rather less than 1 meter. The lens that brings the point
of reversal to 1 meter is one that corrects all the myopia
but 1. D., which must be added to the strength of the lens
to get the total myopia.
When the plane mirror is employed and the distance
varied, that distance must be measured, or, at least, ap-
proximately estimated, and the myopia corresponding to
it added to that represented by the correcting lens em-
SKIASCOPY. 139
ployed. The accurate determination of the point of
reversal requires it to be brought about ^ to 1 meter
before the eye.
Hyperopia. — In hyperopia the rays from the retina
emerge from the eye divergent. There can be no inverted
image, no point of reversal, until a convex lens strong
enough to more than correct it, is placed before the eye.
The light in the pupil will move " with " the light on the
face with a plane mirror, and "against" the light on the
face with a concave mirror at all distances. To measure
the hyperopia the rays which leave the patient's eye
divergent must be rendered convergent by a convex lens,
as L in Fig. 59. The position B of the point of reversal
FIG. 59.— Rays emerging from a hyperopic eye rendered convergent to give a
point of reversal.
for this myopic combination of the eye and lens is then
determined, and thus the amount of myopia that the lens
causes.
The lens L may be regarded as doing two things. Part
of its effect is to make the divergent rays parallel, cor-
recting the hyperopia ; the remainder of its strength
makes the parallel rays convergent, causing an artificial
myopia. The amount of the lens-strength causing con-
vergence of the rays, deducted from the whole strength
of the lens used, gives the strength required to correct the
hyperopia. Thus with + 3. D. lens, causing 1. D. of
artificial myopia, 3. D. — 1. D. = 2. D., the amount of
lens-strength required to correct the hyperopia in the
eye.
Emmetropia. — When the eye, tested as for hyperopia,
shows an amount of myopia produced just equal to the
strength of the convex lens used, it is evident that the
140 EMMETROPIA.
hyperopia of the eye was 0 — that is, that the eye was
erametropic to start with.
Appearance of the I/ight in the Pupil. — When
the surgeon's eye is near the point of reversal, it sees the
patient's retina enormously magnified and the movement of
the light and shadow in the pupil appears correspondingly
rapid. When the surgeon's eye is far removed from the
point of reversal, when there is much uncorrected myopia
or hyperopia, the apparent movement of the light and
shadow in the pupil is slow. Just at the point of reversal,
or at a great distance from it, the illumination is found
comparatively feeble, and the boundary between light and
FIG. 60.— Appearance of light in the pupil : A, about 1. D. from the point of
reversal, and B, about 5. D. from the point of reversal.
shadow indefinite. At about 1. or 2. D. from the point
of reversal, the brightest illumination and most distinct
movement of the light and shadow in the pupil are ob-
served. When these points are borne in mind, the
rapidity in movement and, to some extent, the brilliancy
of illumination become approximate indications of the
amount of ametropia to be corrected.
Of the appearance of the pupillary light-area in regular
astigmatism, aberration, and irregular astigmatism, more
will be said in connection with these forms of ametropia.
Practical Applications of the Test. — The room
should be darkened and the lamp-flame shaded by an
opaque chimney, the circular opening for the emission of
light being turned toward the surgeon's eye. For the
plane mirror the source of light is to be kept as close to
the surgeon's eye as possible (see Fig. 56), and must be
SKIASCOPY. 141
movable. With the concave mirror the light should be
placed behind the patient, about 2 meters from the sur-
geon ; and the opening in the shade may be 25 to 30 mm.
in diameter, or the shade can be omitted. This gives the
concave mirror an advantage when the test must be
applied away from office facilities.
The mirror, being turned so as to reflect the light into
the patient's eye, is rotated slightly from side to side. If
with the plane mirror the light moves " against " the light
on the face, there is a point of reversal between the sur-
geon's eye and the patient's eye. Its position is to be
determined by coming closer to the patient, or by placing
a concave lens that will bring this point of reversal to the
distance of the surgeon's eye.
If the movement with the plane mirror is " with " the
light on the face, there is no point of reversal in front of
the surgeon's eye, but one must be brought there with a
convex lens. If the convex lens that brings the point of
reversal to a certain position be weaker than the amount
of myopia corresponding to that distance, the case is one
of low myopia. If the amount of myopia exactly equals
the lens-strength, the eye is emmetropic. If the myopia
produced by the convex lens be less than the strength of
the lens, the eye is hyperopic. The point of reversal is
to be ascertained by repeated trials both from within and
from beyond it. Generally its location will be most ac-
curately determined by fixing it at the greatest distance at
which movement " with " the light on the face is seen
with the plane mirror, or the shortest distance at which it
is noticeable with the concave mirror.
To secure accuracy, it is well to make the final deter-
mination with the point of reversal as far from the eye as
the movement of light and shade can be certainly recog-
nized. If the pupil has the same refraction in all parts,
this distance may be 1 meter. If the movement has to
be watched in a comparatively small portion of the pupil,
the refraction and movement there being different from
the refraction and movement in other portions, it is neces-
sary to make the test from a shorter distance.
142 THEORY OF THE OPHTHALMOSCOPE.
THE INDIRECT METHOD OF OPHTHALMOSCOPIC
EXAMINATION.
When the eye is viewed with the ophthalmoscope from
a distance greater than that of the point of reversal, the
image obtained is always an inverted image. In the
shadow-test that image is not accurately focussed, so that
the relations of its different portions are not recognized,
as in the ordinary ophthalmoscopic examination. If,
however, the myopia be of high degree, so that the in-
verted image is formed close to the eye, it may be viewed
from some little distance, where it can be focussed and
seen distinctly, so that not only the different portions are
recognized, but any marked anomaly or evidence of dis-
ease can be studied.
If the eye be not myopic, by placing 2 to 3 inches be-
fore it a very strong convex lens (12. to 20. D.) called the
object-lens, an inverted image of the fundus can be formed.
The surgeon's eye must be placed beyond this, far enough
to focus it. By placing the object-lens at or near its focal
distance in front of the eye, the pupil is so magnified that
it appears to occupy the greater part of the object-lens,
enabling the surgeon to see a considerable part of the
fundus at once. With a 2-inch object-lens, the lens
would be 2 inches in front of the eye, and the image
formed about 2 inches in front of it. Then the surgeon
must place his eye far enough away to focus this image,
say 12 inches from it, making it 16 inches from the eye
under observation. This distance may be shortened some-
what by placing back of the ophthalmoscopic mirror a
convex lens of from 3. to 5. D, to aid the surgeon's power
of accommodation.
In the indirect method a larger part of the fundus' may
be seen at once, so that it is easier to make search for
gross ophthalmoscopic changes. On the other hand, the
image of the fundus thus obtained is less magnified than
that studied by the direct method, so that slight lesions
are less readily recognized. The method is, therefore, of
use for a general survey of the fundus.
OPHTHALMOSCOPIC EXAMINATION. 143
SPECIAL METHODS.
I/enses Before the Eye. — The ophthalmoscope is
usually furnished with a mirror that gives the best retinal
illumination when the eye is approximately emmetropic.
On this account, in very high hyperopia or myopia, the
most satisfactory ophthalmoscopic examination can usually
be made by placing in front of the patient's eye a lens
which approximately corrects his ametropia, instead of
depending on the lenses back of the ophthalmoscopic
mirror, which have no influence on the pencil of rays
entering the eye to illuminate the retina.
In examining an opacity, tumor, or detached retina,
close behind the crystalline lens, place a strong convex
lens, 20 to 30 D., in front of the eye, and make the
ophthalmoscopic examination through this.
Use Of Direct Sunlight. — In blind eyes with
hazy media, or to see back of a detached retina, ophthal-
moscopy by direct sunlight is of great value. The sun
must shine directly upon the ophthalmoscopic mirror,
but its rays must not be concentrated upon the surface of
the eye or face, nor upon the retina. This is guarded
against by using a plane mirror, or by care as to the dis-
tance from the concave mirror to the eye. Direct sunlight
should be thrown on the eye but a short time, and the
attempt repeated after a few minutes' rest. Such light
has greater penetrating power than ordinary illuminants,
revealing details otherwise hidden by hazy, vitreous, or
detached retina.
Influence of I/ight on the Color of the Fundus.
— The color of the fundus, .described page 87, is that seen
with the ordinary gas or lamp flame. By changing the
color of the source of light, the colors of the eye-ground
may be completely altered. With direct sunlight, or
diffuse daylight, the fundus of the eye appears paler and
more yellow. With the Welsbach mantel it is paler, and
the whites more bluish or greenish. With the mercury
vapor lamp the general color of the fundus is green, the
optic disk greenish, and the retinal vessels a deep purple.
144 PRESBYOPIA.
CHAPTER VII.
ERRORS OF REFRACTION, CYLINDRICAL LENSES,
PRESBYOPIA, AND THE WEARING OF GLASSES.
PRESBYOPIA.
EVEN with the emmetropic eye, increasing rigidity of
the crystalline lens diminishes the power of focussing on
the retina the divergent rays that come from near objects.
On this account the near point of distinct vision recedes
from the eye. Reading and similar near work become
difficult, and later impossible. When this loss of accom-
modation reaches such a degree as to interfere with the
patient's ordinary occupation, the condition is called pres-
byopia or old sight.
Presbyopia begins before the accommodation is so far
lost as to absolutely prevent the seeing of near objects.
The ciliary muscle, like other muscles, is capable, for
brief periods, of stronger contraction than can be kept up
continuously. An eye cannot keep up for continuous
reading the effort it can make during a brief test to as-
certain the near point. Usually the amount of accom-
modation which can be sustained for continuous work is
about two-thirds of the total accommodation of which
the eye is capable. Hence when two-thirds of the total
accommodation is less than the amount required for near
work, presbyopia begins, and the aid of a convex lens is
required.
The symptoms of presbyopia may be either the actual
indistinctness of near objects, or evidence of strain after
using the eye for near-seeing. The patient finds himself
unable to read fine print especially at night, or he has to
hold the print too far away. Sometimes, although on be-
ginning near work the sight is clear, it suddenly becomes
dim after a time, the print seeming to run together or
blur. Then, if the eyes are closed for an instant, the
power of near-seeing is regained, and continues for some
ERRORS OF REFRACTION. 145
time, when it again fails suddenly. These blurrings,
which are due to sudden involuntary relaxation of the
ciliary muscle, tend to become more frequent the longer
the eifort is continued. They may also occur from strain
of accommodation in connection with hyperopia in young
persons. More frequently before there is any actual in-
ability to see clearly for near work, there come evidences
of strain from its performance. After reading or sewing,
particularly in the evening, the eyes smart or burn, or the
following morning they look red ; or there occur repeated
attacks of conjunctivitis.
The symptoms of presbyopia usually begin between the
ages of forty or fifty years. They begin earlier in hyperopic
eyes which are compelled to use part of their accommodation
for the correction of their hyperopia. In myopic eyes
less accommodation is required for near vision, and pres-
byopia begins later. If the degree of myopia is such that
ordinary near-seeing can be done without any use of the
accommodation, presbyopia never occurs.
Diagnosis. — Between forty and fifty years of age,
symptoms of eye-strain or difficulty of near-seeing grad-
ually develop and increase. Distant vision is good with-
out glasses, and rendered worse by them ; near vision is
improved or made easier by convex lenses.
Treatment. — The treatment for presbyopia is either
abstinence from near work or doing it only with such aid
from convex lenses that not more than the proper pro-
portion of the accommodation need be used. Ordinarily
two-thirds can be used, but some patients can continu-
ously use three-fourths of their accommodation. Others,
especially younger people, cannot safely employ more
than one-half.
The accommodation is measured by finding the short-
est distance at which the finest type can be clearly seen.
A near vision test-card being held at 15 or 20 inches from
the eye, the patient is asked to read the finest type he can
see. If he reads the 20-inch (half-meter) type, the card
is pushed gradually toward him until he can no longer
see it clearly. Its distance from the eye is then meas-
10
146 TREATMENT.
ured, this being the focal distance of the lens, having a
focussing power equivalent to the accommodation. (See
table of lenses and focal distances, page 118.) To get the
full amount of accommodation, the patient must sometimes
be coaxed to make a special effort.
Having ascertained the amplitude of accommodation,
two-thirds of that amount must be subtracted from the
focussing power required for near work. The difference
will be the refractive power of the lens needed to cor-
rect the presbyopia.
For example, if an emmetropic eye can read the 20-
inch type clearly at 13 inches, or can just make out the
13-inch type at that distance, it proves clear focussing at
13 inches, the focal distance of a 3. D. lens. The
patient then has 3. D. accommodation. Two-thirds of
this, or 2. D., is *vhat we may expect him to use safely
'for continuous near work. Now if he lias to read and
write at a distance of 12 inches, where 3.25 D. of focus-
sing power will be required, he must make up the dif-
ference between 3.25 D. and 2. D. or 1.25 D. by convex
lenses of that strength, when doing near work.
The following table, based on the decline of accommo-
dation, as shown in the table on page 126, indicates for
different ages the near-point in inches, amplitude of ac-
commodation in diopters, two-thirds of that amplitude or
accommodation available for near work, and the differ-
ence between the available accommodation and the focus-
sing power, 3. D., required to correct the presbyopia for
that working distance.
TABLE V. — Accommodation and Lenses for Presbyopia.
Age. Near-Point.
Total Accom.
Available A.
Lens Required.
40 7 in.
5.5 D.
3.67
0.
45
10 in.
4. D.
2.67
0.50
50
16 in.
2.5 D.
1.67
1.50
55
31 in.
1.25
0.83
2.25
60
78 in.
0.5
.33
2.75
65
00
0.
0.
3.
Such a table should never be used for prescribing glasses,
for it only represents an average, from which the purlieu-
PRESBYOPIA. 147
lar case may differ greatly. Neither should glasses be
prescribed in any way from the age of the patient, for
besides individual variation in the loss of accommodation,
hyperopia and myopia influence the glass required, and
must always be considered. Nor can the glasses required
for presbyopia be guessed at from the blurring of the
patient's vision, since this depends as much on the size of
the pupil as upon the perfection of the focussing. In
every case the total accommodation should be ascertained
by the determination of the refraction of the eye and its
near-point of distinct vision. If the patient has some
working distance other than one-third of a meter — 13
inches — the available accommodation must be deducted
from the focussing power required for that distance, to
find the lens required. Presbyopia complicated by hyper-
opia or myopia is discussed in connection with their
treatment.
Prognosis. — Presbyopia continues to increase until all
power of accommodation is lost, at the age of fifty-five or
sixty. Until this time the lenses given to correct it should
be changed every two or three years. After that age
no change of lenses may be required for several years.
HYPEROPIA.
Hyperopia (hypermetropia or far-sight] is the most
common error of refraction, being present in about 70
per cent, of all eyes. To the savage it is far less dan-
gerous than myopia, which lessens his power to secure
food and guard against enemies. But with civilization
and the general employment of the eyes for near work,
hyperopia becomes a serious defect.
The hyperopic eye refracts parallel rays toward a point
behind the retina ; the retina is in front of the principal
focus of the dioptric media. The hyperopic eye is rela-
tively too short, either because its refracting surface is
not sufficiently curved, hyperopia of curvature; or be-
cause its anteroposterior axis is actually shorter than that
of the average eyeball, axial hyperopia. In the majority
148 OPTICAL NATURE.
of cases the latter is the condition present ; and in high
hyperopia the eyeball may be noticeably small in all its
dimensions, so that it does not properly fill the orbit.
The course of the rays in the hyperopic eye is shown
in Fig. 61 ; parallel rays passing in the course of the
FIG. 61. — Course of rays in the hyperopic eye, with and without the correcting
lens.
broken lines would be focussed at F, back of the retina. To
cause the rays t<f be focussed on the retina they must be
given a certain amount of convergence before they reach
the eye ; they must be turned in the direction of the
dotted lines toward .R. R is called the far-point of the
hyperopic eye. It is a kind of " virtual " far-point,
situated behind the eye. It is the principal focus of the
lens L that will correct the hyperopia. When rays are
converged toward it, the refractive power of the eye is
sufficient to focus them on the retina, as shown by the
solid lines.
Rays emerging from a point of the retina of the
hyperopic eye traverse the same path in the opposite
direction. As they pass out of the cornea they are not
rendered parallel, but still diverge as though they came
from the " far-point " of the eye R ; and they require a
convex lens L, with its principal focus at jR, to make them
parallel. If the lens be placed at the eye, its focal dis-
tance will be the distance of the far-point back of the
eye ; but if the lens be placed in front of the eye, its focal
distance must be proportionately increased. Thus, if the
far-point be 4 inches back of the cornea, the focal distance
of a correcting lens placed at the cornea must be 4 inches
(10. D. lens) ; but if the lens be placed l inch in front
of the cornea, its focal distance must be 4^ inches (9. D.
HYPEROPIA. 149
lens). Either of these lenses at its proper distance from
the eye will render clear distant objects as test-letters ; or
it will render parallel the rays that pass from the patient's
retina to the surgeon's eye through the ophthalmoscope.
Hyperopia may also be usually corrected by the proper
amount of accommodation, having the effect of a convex
lens.
Causes. — Hyperopia is due to a congenital departure
from the proportions of the emmetropic eye, or it may arise
from the removal of the crystalline lens, or cicatrical flat-
tening of the cornea.
Varieties. — The theoretical varieties, hyperopia of
curvature and axial hyperopia, have been mentioned.
The chief clinical varieties depend on the relations of
the hyperopia to the accommodation. When _the accom-
modation is entirely relaxed, as under the influence of a
cycloplegic, all the hyperopia is revealed. This is the
total hyperopia. When the hyperopia is so great that the
maximum exertion of the accommodation leaves part of
it uncorrected, this part is called the absolute hyperopia.
When, as frequently happens, the habit of correcting
hyperopia by accommodation is so strong that it is impos-
sible for the patient to look at even a distant object with-
out using some accommodation, although he may have a
convex lens before the eye that renders accommodation
unnecessary, the part of the hyperopia he cannot help
correcting is called the latent hyperopia. All the hyperopia
that is not latent is the manifest hyperopia. That part of
hyperopia between the latent and the absolute, the part that
can be corrected by the accommodation or left uncorrected
at pleasure, is the facultative hyperopia. The relations of
these different varieties to each other and to the voluntary
and involuntary accommodation are shown in the follow-
ing diagram :
Total A ceo
Involuntary A.
mmodation.
Voluntary A.
Latent H.
T
Facultative H.
Man
otal Hyperopi
Absolute H.
ifest H.
a .
150 VARIETIES.
On trying convex lenses before an eye which presents
all these varieties of hyperopia, commencing with a weak
lens, vision is improved as the lens is made stronger until
all the absolute H. is corrected ; when with the aid of all
the accommodation the full vision may be obtained. In-
creasing the strength of the lens yet further, the full
vision is still obtained, but with less effort of accommoda-
tion until all of the facultative H. is corrected, no volun-
tary accommodation being needed. But on still increasing
the strength of the lens distant vision gets worse, since
the accommodation cannot be further relaxed ; and a part
of the latent H. is doubly corrected, making the eye to
that extent near-sighted.
In early life none is absolute unless the total hyperopia is
of very high degree. After fifty or fifty-five it all becomes
absolute. Before* fifty, hyperopia is partly latent in about
one-third of all cases, when both eyes are tested together.
When each eye is tested separately, a much higher pro-
portion fail to manifest all their H. H. is more apt to
become latent when the eyes have been strained or irri-
tated ; and the proportion that is latent may vary greatly
from day to day, or even in a few minutes.
Symptoms. — In early childhood, hyperopia causes con-
vergent squint, which arises in the larger number of cases
before six years of age. Squint may be associated with
any degree of H. ; but it is a high degree of H., 2. to 6.
D., though not the highest degree, that most frequently
causes squint. Squint due to H. is very often variable in
degree or intermittent.
Hyperopia becomes a cause of eye-strain. When the
eyes begin to be much used for reading, looking at pictures,
etc., there arises chronic hyperemia of the conjunctiva and
lid-margins. Later, as puberty is approached, headache
becomes an important symptom. From that time up to
middle life, hyperopia, with or without astigmatism, con-
tinues to be the most frequent and most important cause
for headache. Later, H. gives rise to the symptoms of
presbyopia, coming on some years earlier than it other-
wise would.
HYPEROPIA. 151
Headaches caused by hyperopia are not peculiar to
that condition ; but are similar to headaches from loss
of sleep, exhaustion, anemia, etc. The pain is most
frequently quite dull and confined to, or most severe in,
the frontal region. It may be constant (usually with ex-
acerbations of greater severity), may be felt only at such
times as the eyes have been much used for near work, or
it may take the form of distinct attacks of migraine. In
some cases the periods of its occurrence are periods of
specially hard use of the eyes ; in others they are the
menstrual periods, or any time of nerve-exhaustion. In
some cases the headaches cease as soon as the H. is cor-
rected, Or the eyes are placed under the influence of a
cycloplegic ; in others they disappear quite gradually, or
only after improvement of the general health.
Imperfect distant vision from hyperopia alone is
uncommon in early life, and is only met with when the
H. is very high. Cases of this kind are frequently mis-
taken for cases of myopia. The child inclines to hold
things very close because of his imperfect vision, and
by holding the object very near he gets a large retinal
image. Then his strong convergence is accompanied
with a strong contraction of the pupil, which renders his
retinal images less indistinct. When the power of
accommodation has been lost, even the lowest degrees of
H. will render vision imperfect. When the eyes are
used much for near work, even early in life, moderate
degrees of H. are liable to cause sudden failure of
accommodation, particularly toward the latter part of
the day. This has been mentioned as a symptom of
presbyopia.
The severity of the symptoms of hyperopia gives little
indication of the degree of the defect. One person with
high H. may go until nearly forty with no serious incon-
venience ; while another, with much less, is compelled to
wear glasses constantly from childhood. Symptoms are
likely to arise first when the eyes have been subjected to
some special strain of near work, as during term exam-
152 SYMPTOMS.
inations at school ; or they may appear after an attack
of acute illness, like influenza or typhoid fever.
Diagnosis. — Distant vision is often very good, if the
accommodation be sufficient. If vision be imperfect, it
will be improved on looking through the pinhole disk.
Near vision is relatively the worse. The near-point of
distinct vision is not so close as it should be at the
patient's age. Vision is not impaired by convex lenses
unless they are too strong. With the ophthalmoscope the
fundus is clearly seen without a lens, or with a convex
lens. By skiascopy an erect image (movement " with "
light on the face with plane mirror) is obtained through
a convex lens, beyond the focal distance of the lens. The
amount of H. is to be measured as described on page 139.
With test lenses, if the power of accommodation has
been removed by* age or the use of a mydriatic, each eye
should be tested alone. The convex lens giving the
best distant vision will be the one which focusses on the
retina rays from the test-object. If the test-object is 4
meters away, the rays from it are 0.25 D. divergent, and
truly parallel rays would be focussed on the retina by a
lens 0.25 D. weaker. This 0.25 D. must therefore be
subtracted from the lens chosen at 4 meters to find the
true correction of the hyperopia. With the test-type at
6 meters the theoretical deduction would be one-sixth of
a diopter.
When the accommodation is active, the hyperopia is
best measured by testing both eyes together. Begin by
placing before them convex lenses strong enough to
somewhat blur distant vision. Then gradually weaken
these, by holding successively stronger concave lenses
before them, or by replacing by weaker convex lenses.
Care must be taken not to allow the patient to look at the
test-type without glasses, and thus bring the accommoda-
tion into active use. When good vision has thus been
obtained, cover one eye and then the other ; if the vision
of one eye is still imperfect, make the convex lens before
it still weaker, until vision is as good as that of the
other eye, or is not further improved by the weaken-
HYPEROPIA. 153
ing of the glass. This method presupposes that each eye
is capable of good vision, and is free from astigmatism,
or has it already corrected.
Treatment. — Hyperopia of itself requires no treat-
ment. Most eyes that do the moderate work required of
them, without damage or inconvenience to their possessors,
have hyperopia of low degree ; but whenever symptoms
liable to arise from H. occur, the probability of their
being due to it is to be considered, and the standard ther-
apeutic resources will not have been employed without
use of proper correcting glasses. For headache and conges-
tion or inflammation of the eyes or lids, the correcting
lenses should be worn constantly. Where no incon-
venience is experienced except in direct connection with
use of the eyes for near work, the glasses may be worn
for near work only. In exceptional cases where the
hyperopia is high, and the symptoms it causes are insig-
nificant and only connected with near work, a partial cor-
rection may be worn at such times.
Sometimes the full correction of the hyperopia, in
young persons who have some of that hyperopia latent,
causes at first blurring of distant objects. If the glasses
have been correctly chosen, this blurring will pass away
after a time, the H. becoming all manifest. Sometimes
this requires several weeks, in other cases it requires but
a few hours. It indicates an improper activity of the
ciliary muscle, which passes away with the wearing of
glasses, or more quickly by the use of a cycloplegic.
Until it is overcome, the eye cannot be regarded as quite
well, and the full benefit of the glasses will not be expe-
rienced. The patient should be previously warned that
this may occur when the glasses are first worn, or whenever
the eyes are particularly tired or irritated ; and that it is
an indication, not for removal of the glasses, but rather
for the steady wearing of them, with lessening of the near
work required of the eyes.
It is generally easier for the eyes to become accustomed
to the full correction than to a partial correction that in-
cludes some of the latent H. ; and those cases that have
154 TREATMENT.
the most trouble in becoming accustomed to the full cor-
rection often experience the greatest benefit from it. If
it is known that the patient, even after an explanation of
the difficulty, will not wear correcting lenses long enough
or steadily enough to get the benefit of them, a partial
correction of the hyperopia may be prescribed, with the
warning that the glasses will soon need to be changed and
that full relief may not be secured until the full cor-
rection is worn. The full correction of hyperopia will
not be satisfactory unless the glasses at the same time ac-
curately correct any astigmatism present and any differ-
ence of refraction between the two eyes.
When the hyperopic eye becomes also presbyopic, the
glasses that correct the hyperopia and serve for far seeing
will not be sufficient for near work, for which another
pair of lenses nfust be worn. The glasses for near work
may be determined by placing on the patient the lenses
correcting his H., and with them determining the near
point, and from it the correction for presbyopia, to be
added to the correction for H. for continuous near work.
Or one may determine the " near point " directly, without
glasses, and from it and the known hyperopia calculate
the glasses that will enable the patient to work at the re-
quired distance without using more than two-thirds of his
accommodation.
Prognosis. — At birth almost all eyes are hyperopic,
and during early childhood some become less hyperopic, and
some even myopic. But from the age of fifteen years the
general tendeny is for H. to increase, probably by the slow
growth of the crystalline lens, which continues until old age.
As the lens increases in all dimensions, its focus lengthens.
In early adult life the increase of H. is usually very
slight ; but it is often more rapid after middle age. In
extreme old age hyperopia may diminish through changes
in the crystalline lens. No definite opinion can be given
as to how often glasses correcting hyperopia require to be
changed. Usually it is not for several years, sometimes
many years, but occasionally within a year or two. The
hyperopia following the extraction of the crystalline lens
HYPEROPIA.
155
generally increases markedly for several months after the
operation.
MYOPIA.
Myopia (brachymetropia,. short sight or near sight) is
extremely rare among savages. But it is quite common
among civilized people, arising as the result of disease
caused or favored by the overuse and strain of the eyes for
near seeing. It is most frequent among students and
others who lead sedentary lives and do much close eye-
work, such as tailors, dressmakers, etc. ; while among
outdoor laborers, farmers, and sailors, it is comparatively
rare.
The myopic eye focusses parallel rays in front of its
retina, the retina is behind the principal focus of the
dioptric surfaces. It is relatively too long, either because
the refracting surfaces are too much curved — myopia of
curvature; or because the antero-posterior axis of the
eyeball is really longer than it should be — axial myopia.
Usually the myopia is axial, having been caused by the
yielding of the sclero-corneal coat to the intra-ocular
pressure. When the myopia is very high in degree, the
enlargement of the eyeball causes it to fill the orbit and
protrude, making the eye prominent. The course of rays
in the myopic eye is illustrated in Fig. 62. Parallel rays,
R..
FIG. 62. — Course of rays entering the myopic eye, with and without correcting
lens.
entering in the direction of the broken lines, are brought
to a focus within the vitreous ; and when they reach the
retina they have become divergent again, so that distinct
distant vision is impossible. Rays with a certain amount
of divergence, coming from R, the point for which the
156 OPTICAL NATURE.
eye is optically adjusted — the far-point of the eye — are
accurately focussed on the retina. To focus parallel rays
on the retina it is necessary to place before the eye a
concave lens that will cause them to diverge, as though
they came from the far-point R. Rays emerging from a
point in the retina of the myopic eye, traversing the same
path in the opposite direction, leave the cornea turned
toward the far-point R. They require a concave lens
having its principal focus at R to make them parallel.
Myopia is " corrected " by a concave lens having its
principal focus at the far-point of the myopic eye. The
distance of the far-point from the eye will be the focal
distance of the lens, which, when placed at the eye, will
correct the myopia. But if the lens be placed in front
of the eye, nearer the far-point, its focal distance will
have to be to that extent shorter. Suppose the far-point
to be 3 inches in front of the eye. If the lens be placed
at the eye, a 3-inch (13. D.) lens will correct the myopia.
But if placed a half-inch in front of the eye, the correcting
lens will be only 2^ inches from the far-point, and a 2|
inch (15. D.) lens will be required to correct the
myopia.
The myopic eye is unable to correct its defect by
accommodation. When the accommodation is exerted,
the focus of the parallel rays is brought still farther in
front of the retina, and rays to be focussed on the retina
must reach the eye still more divergent. It can see dis-
tinctly closer than the emmetropic eye of the same age,
and thus has some of the advantage, as well as the disad-
vantages, of an eye with a magnifying glass before it.
Causes and Course. — Myopia is due chiefly to the
straining of the eyes for near work. There seem to be
two important factors in its production — namely, soften-
ing of the scleral coat by congestion, and pressure of the
muscles around the eyes in fixing near objects. These
co-operate with the normal intra-ocular tension to pro-
duce stretching of the sclero-cornoal coat, at the region of
greatest softening and least resistance, usually about the
posterior pole of the eye, or the entrance of the optic
MYOPIA. 157
nerve. An important cause of eye-strain and myopia is
astigmatism. Sometimes the initial softening of the
sclera occurs as a result of acute general disease, as after
one of the eruptive fevers ; and vascular tension has been
credited with an important influence in causing it.
The process of distortion, beginning in hyperopic eyes,
leads first to diminished hyperopia, and later to myopia.
In its earlier stages it is often arrested by diminished strain
of the eyes on account of pain, or other symptoms of
irritation that arise. If the distention and the thinning
of the sclera have not progressed too far, the normal in-
creasing rigidity of the sclera tends to arrest it in early
adult life. Often when one eye is practically useless, and
convergence to secure binocular vision is given up, the
increase of myopia ceases. But generally the more the
sclera is thinned the more rapidly does it continue to
yield to intra-ocular pressure, until extreme myopia ter-
minates in blindness, by vitreous opacities, atrophy of the
choroid, or detachment of the retina.
As myopia increases, a vicious circle is established.
The patient, disabled for distant seeing, uses his eyes
more and more for near work. At the same time near
work becomes harder and more dangerous, because of the
change in shape of the eyeball. The normal eye is a
sphere, turning in a spherical socket, equally well in all
directions. In high myopia the eyeball always becomes
more or less ovoid, lying in the space included by the
cone of muscles that arise from the apex of the orbit and
pass forward to be attached to its anterior segment. This
ovoid eyeball fits in its socket only in one direction. If
turned from this direction it must push aside the tissue
composing its socket, or be compressed by it. The ovoid
socket having the direction of the muscular cone, and the
visual axis being nearly in the direction of the long axis
of the eyeball, there is almost always a tendency for
highly myopic eyes to diverge. Because of this tendency
to divergence, and the necessity of excessive convergence
for binocular vision at the only distance at which clear
vision is possible, the myopic eye is subjected to excessive
158 CAUSES AND COURSE.
effort of convergence, with increased pressure on the
sides of the globe, tending to distend it still further
anteroposteriorly. This injurious influence continues
active until the need for excessive convergence is removed
by the wearing of glasses, or until binocular vision ceases,
either by the practical blindness of one eye or by its
actual divergence — divergent squint.
Varieties. — Besides axial myopia and myopia of
curvature (see p. 155), theoretically there might be added
myopia due to changes in the index of refraction of one
or more of the dioptric media. The temporary myopia
referred to as a sequel of iritis (Chapter XI) has been
ascribed to this cause ; and the myopia which comes on in
old age, often as a forerunner of cataract, is due to in-
crease in the refraction of the lens nucleus. Progressive
myopia is a teAi that would apply to all cases of M. at
some stage. But it is usually intended to imply that the
case continues progressive while under observation.
Malignant myopia is applied to a small group of cases
which, in spite of treatment and avoidance of near work,
continue to go steadily from bad to worse until all useful
vision is lost. The same term is sometimes applied to
any case that has gone so far that there remains but little
sight, and little to expect from treatment, although such"
a condition may have been produced only by reckless
disregard of all hygienic measures.
It is also convenient to classify myopia according to its
degree as follows : Low M., not over 2. D., some accom-
modation being required for most kinds of near work.
Moderate M., from 2. D. to 4. D., near work being pos-
sible without accommodation and without excessive con-
vergence. High M., from 4. to 10. D., binocular vision
being still possible but with excessive convergence. 1 >/•//
high M., over 10. D., binocular vision being usually
impossible without concave lenses.
Symptoms. — Myopia always causes impairment of
distant vision. In a few cases this impairment has not
been noticed until the eyes come to be tested ; but gener-
ally it is the first thing to attract attention, and is usually
MYOPIA. 159
quite striking. It depends on the degree of the myopia
and size of the pupil, which is often rather large in
myopic eyes, and on retinal lesions that accompany the
myopia. In any case the near vision is comparatively
good, and the near-point closer to the eye than normal.
With high myopia the impairment of vision prevents
the patient from recognizing and imitating, or responding
to the facial expression of others. Hence, the face of the
myope often looks dull, unresponsive, or expressionless.
When trying to see distant objects clearly, the myope
almost closes the lids, to narrow the circles of diffusion
on the retina. This habitual " nipping " of the lids also
affects the facial expression, and gave rise to the term
myopia. Imperfect distant vision gives a distaste for
outdoor sports that require good sight, excludes from
certain occupations, and turns the patient to sedentary pur-
suits requiring distinct vision at short distances only.
These symptoms disappear when correcting glasses are
worn continuously.
The difficulty of turning the ovoid myopic eye in its
socket causes the patient partly to substitute movements
of the head and body for those of the eyes. This causes
a peculiar carriage of the head when walking, and a
characteristic attitude and movement of the head in read-
ing. Instead of holding the head and book still, and fol-
lowing each line by a movement of the eyes, the whole
head is turned somewhat, from side to side, the book
being at the same time moved in the opposite direction.
These movements are greatly exaggerated when the
patient reads without glasses, because of the greater angle
subtended by the line when held very close to the eye.
If the book or other object looked at is too heavy to raise
to the eyes, the head is bent down toward it, interfering
with the return of venous blood in the neck, and favoring
congestion of the head and eyes. The connection of
divergent squint with myopia is farther considered in
Chapter VIII.
The difficulty of executing ocular movements may cause
frequent and severe aching in the eyes, besides the head-
160 SYMPTOMS.
aches which may occur in connection with myopia, as
with hyperopia or astigmatism, through eye-strain. It
should be noted that with myopia, although near vision
without accommodation is theoretically possible, it is not
usually accomplished in practice. The difference in the
degree of M. between the eyes, and the strong effort of
convergence required, nearly always provoke some effort
of accommodation, and a slight inaccuracy in the distance
of the near work may compel as much accommodation as
the emmetropic eye is usually required to exert. Thus,
a myope having M. of 10. D., holding his book 1 inch
nearer his eyes than necessary, would need to use 3. D.
of accommodation — the same as an emmetrope reading at
13 inches.
The occurrence of muscse volitantes with myopia has
already been aMuded to (p. 42). Moving clouds before
the sight may indicate the presence of vitreous opacities
of any size. They usually appear rather suddenly after
some especial strain of the eye. With the ophthal-
moscope the opacities may be identified, and their progress
watched. If large they rarely disappear entirely, although
they become less annoying. The tendency is for the
vitreous slowly to become more disorganized and fluid,
the opacities becoming more freely movable, even though
the degree of myopia be not increasing.
Cataract occurs ultimately in a large proportion of
highly myopic eyes. It is apt to be of slow develop-
ment and dark in color — the so-called choroidal cataract.
Posterior polar cataract is sometimes seen in myopic eyes
for many years before there is any general opacity of the
lens.
Choroidal changes almost invariably mark the progress
of myopia. They begin usually with haziness or a fluffy
appearance, which is often confined to the temporal side
of the optic disk, but may be more general. Then there
appears thinning of the choroid with irregular deposit of
the pigment and atrophy of the choroidal stroma, so that
the sclera shows through in the form of a crescent at the
temporal side of the disk. Such a myopic crescent is
MYOPIA.
161
shown in Figs. 33 and 34 at different stages in its develop-
ment. Exactly similar appearances brought about in the
same way may be seen in hyperopic eyes. But as the eye
passes over into myopia, the choroidal changes generally
continue. A crescentic portion of the choroid adjoining
the atrophic crescent becomes disturbed, infiltrated, and
atrophied, and by this process the myopic crescent extends.
Fig. 34 shows the extension of choroidal changes beyond
the original crescent.
The distention of the eyeball continuing, the atrophic
area extends, so that it assumes rather a triangular form
with the base toward the disk and the apex toward the
FIG. 63.— Fundus of highly myopic eye with "dragged" disk, large "conus,"
general atrophy of retinal pigment, revealing the choroidal vessels, and
patches of choroidal atrophy, one of which is commencing in the macula.
macula. Such an area is called a conus. At the same
time areas of thinned and disturbed choroid become
noticeable in other parts of the fundus, especially near the
11
162 SYMPTOMS.
macula, and tend to undergo atrophy. These appearances
of advanced choroidal change are illustrated by Fig. 6->.
The degeneration of the ehoroid is usually attended
with vitreous opacities. In a few cases the crescent of
atrophy is situated not at the temporal, but at the upper,
lower, or even nasal margin of the disk. As it grows
larger it tends to encircle the disk.
A decided atrophy at the temporal side of the disk
usually accompanies the marked bulging of the sclera
that sometimes occurs at this point, called posterior
staphyloma. In this case the disk, being tilted so as to
face rather laterally into the eye and not forward toward
the pupil, appears foreshortened, narrow from side to side,
and therefore more of an ellipse, with the long axis verti-
cal. The stretching also causes the vessels to run straight
across the regiorf of atrophy, as shown in Fig. 63, giving
the appearance known as the " dragged disk."
The retina in the irritative stages of myopia may be
swollen and hazy with increased reflexes. The "Weiss
reflex " (p. 100) at the temporal side of the disk has some
significance as a sign of swelling. Later, in some parts the
retina may atrophy with the underlying ehoroid, although
generally it does not. In very high myopia the retina is
liable to detachment, probably from retraction of parts of
the disorganized and partly cicatricial vitreous.
Diagnosis. — Imperfect vision from any cause, induc-
ing the patient to hold print or small objects close to the
eyes, is liable to be called near-sightedness. But in
myopia near vision is always relatively better than dis-
tant. A hyperope may be able to read print at 5 inches
that he cannot read at 20 inches, but type four times as
large will be read more easily at 20 inches. But the
myope able to read 10-inch type at 5 inches will not be
able to read 40-inch type at 20 inches.
We have then in myopia impaired distant vision, which
is improved by the pinhole disk. Near vision is rela-
tively good, and the near-point closer to the eye than for
the emmetropic eye at the same age. With the ophthal-
moscope the fundus cannot be seen clearly in the erect
MYOPIA. 163
image, without the use of a concave lens ; but on draw-
ing back from the eye one may, in very high myopia, see
clearly an inverted image of the fund us. By skiascopy
(p. 134) a point of reversal is found between the surgeon and
the patient's eye, or closer to the patient's eye than the
principal focus of a convex lens placed in front of it.
Concave lenses render clearer the distant vision. Under
a cycloplegic the lens which gives the best distant vision
corrects the myopia. When the eyes are not free from
accommodation, the weakest concave lens that will give
the patient his best vision is to be sought, by trying first
lenses that are too weak, and as their strength is in-
creased, noting the one with which vision ceases to
improve. An approximate estimate of the myopia may
be made by measuring the greatest distance at which the
finest type is visible. This will be approximately the
distance of the far-point from the eye, the focal distance
of the lens correcting the myopia.
Treatment. — The first remedy for myopia is the
wearing of correcting lenses. These are necessary to
remove the most important influences that tend to increase
the myopia, and to give the patient the best vision of which
his eyes are capable. In general, they should correct all
the myopia and should be worn constantly. The excep-
tions to this will be noted presently. Such lenses allow
the patient's eye to work under conditions most nearly
similar to those of emmetropia. They induce him to
relax his accommodation entirely when looking at distant
objects — a thing he may not do when it will not bring
clear vision — and to use the normal accommodation for
near-seeing. They discourage excessive convergence,
since with it must occur strain of accommodation. They
enable the patient to enter upon occupations and amuse-
ments requiring distant vision, and to escape from those
which tend most strongly to increase his myopia.
Glasses worn only a part of the time, or which only
partly correct the myopia, do not give these benefits.
Lenses partly correcting myopia may be extremely dan-
gerous. For rays passing through it obliquely a lens acts
164 TREATMENT.
as a stronger lens, and produces a greater refractive effect
than for rays passing in the direction of its primary axis,
perpendicular to its surfaces. The myope with a partial
correction finds this out, finds he can see better or farther
by looking obliquely through his glasses, and does so.
But, besides increased strength, obliquity gives a totally
different and very undesirable effect. It causes a spherical
lens to act as a sphero-cylindrical lens or a sphero-cylin-
drical to act like one having a cylinder of different
strength or differently placed. This exposes the patient
to the dangers of eye-strain from astigmatism, and an
astigmatism that varies with the direction in which the
patient looks.
The exceptions to the constant wearing of the full cor-
rection are : In presbyopia, glasses which allow for the
failure of the accommodation must be given for near
work. They are determined by subtracting from the
correcting lenses worn for far-seeing, the strength required
for correcting the presbyopia which is found, either by
taking the near-point with the correcting glasses on, or by
taking the near-point without glasses, and from it and the
far-point calculating what will be necessary to enable the
patient to do his near work without using more than two-
thirds of his accommodation.
A few persons who have not reached the age of pres-
byopia suffer from continued use of even less than half
their accommodation. Such persons, if emmetropic, use
convex lenses for near work, and if myopic, should have
glasses weaker than their correcting lenses, to use for near
work only. The persons who are better off for a permanent
arrangement of this kind are but few. A larger number
will be helped by wearing weaker concave lenses for near
work, and their correcting lenses for distance, temporarily,
while becoming fully accustomed to the latter.
Patients who have given up or are just giving up
binocular vision should not always be given correcting
lenses. In some cases such lenses may restore binocular
vision^, with advantage to the patient. In other cases
they will lead to persistence in the attempt to use both
MYOPIA. 165
eyes together, and thus to further increase of an already
high myopia, which would otherwise be checked by giv-
ing up binocular vision and the accompanying eifort of
convergence.
Persons who see very imperfectly through their correct-
ing lenses may be distinctly worse off with them, because
of the diminished size of the retinal images. The retinal
image of the myopic eye is larger than that of the em-
metropic eye, because the retina is farther from the nodal
point, but when a concave lens is placed before the eye
the nodal point is shifted back toward the retina. With
the correcting lens at the anterior focus of the eye, about
^ inch in front of the cornea, the retinal images are the
same size as those of the emmetropic eye. But this may
be such a reduction in their size as to cause great annoy-
ance to the myope accustomed to the larger images. Such
a patient may go without glasses, or with a partial cor-
rection, since he will feel no temptation to increase the
effect of the lens by looking through it obliquely.
Operative Treatment. — Persons with very high
myopia experience much annoyance from the strength of
their correcting lenses, their weight, the prismatic effect
if they get slightly out of place, the difficulty in becom-
ing accustomed to them, and the diminished size of the
retinal images. When the myopia amounts to 15. D. or
over, and correcting lenses are not w7orn with satisfaction,
or perhaps when the myopia has reached 13. D. before
the age of puberty, and is still rapidly increasing, in
spite of correcting lenses and abstinence from near work,
it is proper to practise removal of the clear crystalline lens.
This is accomplished in children by needling alone, and
in adults by needling the lens to cause a traumatic cata-
ract, and, before it causes undue swelling of the lens and
irritation of the eye, extracting it like any other soft
cataract.
The removal of the crystalline lens gives much larger
retinal images than the wearing of a correcting lens,
sometimes more than 50 per cent, larger, and if every-
thing goes well, it may be expected to improve the acute-
166 OPERATIVE TREATMENT.
ness of vision to that extent. It deprives the eye of the
power of accommodation ; but to the eye that is very
highly myopic and cannot wear a correcting lens, accom-
modation is useless. The removal of the clear lens is
attended with about the same risks as cataract extraction,
and in some cases confers almost equal benefit. It does
not, however, remove the danger of detachment of the
retina, and sometimes does not prevent a further increase
of the myopia. It should not be done unless it has been
demonstrated with lenses that correction of the myopia
can greatly improve vision, and that such lenses cannot
be comfortably worn. The amount of myopia corrected
by the removal of the crystalline lens varies from 15. D.
to 30. D. The higher the myopia, the greater the effect
that can be expected from the operation. Generally the
eye after operatic* will require correcting lenses for dis-
tant vision and others for near work.
Besides its optical treatment, myopia, if at all progres-
sive, demands rest from near work, or its careful regula-
tion. Rest will sometimes need to be made absolute by
the continued use of a cycloplegic. Regulation includes
care of the conditions under which eye-work is done,
especially avoidance of excessive convergence, and limit-
ing the amount within the endurance of the eyes. After
acute disease care must be taken to avoid eye-work until
the strength has been fully restored ; and any condition
unfavorable to the health and nutrition of the coats of the
eye should receive attention.
Prognosis. — Under the treatment outlined nearly all
cases of myopia will cease to be progressive. But even
if the eye does not become more myopic, if it be already
highly so in early life, there is danger of degenerative
changes in the ocular tissues as the patient grows old. If
the myopia be moderate or low, there is a probability that
it will slightly decrease as the patient grows older,
through continued growth of the crystalline lens. With
correcting lenses even high degrees of M. may become
quite stationary. The writer has seen a case in which
20. D. lenses fitted at the age of nineteen still fully cor-
MYOPIA.
167
rected the myopia thirty years later, although the patient,
a clergyman, had used the eyes to excess in reading and
study.
ASTIGMATISM AND CYLINDRICAL LENSES.
In speaking of lenses and the eye, it has been thus far
supposed that their dioptric surfaces curved equally in all
directions, and that the light coming from one point was
perfectly focussed to another point. To an eye with such
surfaces a point of light, such as a star or distant electric
light, appears as a simple point. Most persons, however,
see such a point of light either as a line, or as a number
of lines of light radiating from a center, the conventional
figure of a star *. This is due to inequalities in the
curves of the dioptric surfaces of the eye, which prevent
light from a point outside the eye from being focussed
perfectly to a point on the retina. Hence this defect is
called astigmatism or astigmia. Astigmatism is divided
into regular astigmatism and irregular. When the word
astigmatism is used without qualification, regular astigma-
tism is meant. It is regular astigmatism that we are
now to consider.
A cylindrical lens, or a "cylinder," represents the
simplest case of such asymmetry of a dioptric surface.
It is bounded on one side by a portion of the surface of a
cylinder. Such lenses and the way they refract light are
represented in Fig. 64, which represents the convex cylin-
drical lens, and Fig. 65, which represents the concave. In
FIG. 64.— Refraction by a convex cylindrical lens, bringing parallel rays to a
focal line.
one direction the lens-surface has a curve like that which
a spherical surface has in all directions, but at right
168
A CYLINDRICAL LENS.
angles to this curve the surface is perfectly straight. A
straight line A A running at the thickest part of a convex,
or the thinnest part of a concave lens, is called the axis
of the lens.
In the direction of its axis a cylindrical lens has no
more effect on the light passing through it than a plate
FIG. 65.— Refraction by a concave cylindrical lens, dispersing rays as though
from a focal line.
of glass with parallel sides. In the direction of its curve
a cylindrical lens focusses light like a spherical lens of
the same strength. If we consider the action of the lens
on the light passing through it in a plane perpendicular
to the axis, we see that the light will continue in this
plane, being turned neither up nor down, and that the
ray passing through A will not be refracted at all, but
that all the rays passing on the right or left will be
turned in to meet this central ray at F. The same thing
happens in all planes perpendicular to the axis, so that
all the light passing through the lens is focussed in the
points of the line FF, which may be called the focus of
the cylindrical lens.
Since a cylindrical lens refracts light only in one plane,
in prescribing or speaking of such a lens it is necessary
to indicate the direction of its axis on a graduated circle
such as is placed on the front of trial frames. On the
scale commonly used in this country the graduation starts
with zero at the right of the horizontal diameter when
the circle is looked at from in front, goes upward to 90°,
which is vertical, and over to 180° at the left of the hor-
izontal diameter. Or the graduation, starting at the left
ASTIGMATISM AND CYLINDRICAL LENSES. 169
of the horizontal diameter, goes downward and then to
the right.
The regular astigmatism of the eye is due chiefly
to the shape of the cornea, and it often is convenient to
speak as if it were wholly due to the cornea. The cornea
curves in all directions, but astigmatism is caused by its
curving more in one direction than in another. The
direction in which it curves most and the direction in
which it curves least are (for regular astigmatism) at
right angles to each other. They are called the principal
meridians of corneal curvature or the principal meridians
of astigmatism. The meridian of greatest curvature is
commonly vertical or nearly so, the meridian of least
curvature horizontal or nearly so. When this is the case,
it is said to be astigmatism according to the rule ; when
the relative curvatures are reversed, it is astigmatism
against the rule.
The refraction of light by an astigmatic eye can be
best understood by combining a spherical + 10. D. with
FIG. 66.— Refraction of light in principal meridians of an astigmatic eye, the
upper part representing the vertical, and the lower part the horizontal meri-
dian.
a cylindrical + 4. D. lens from the trial case (or by using
a spherocylindrical lens, one surface spherical, the other
surface cylindrical, of this strength), and studying how
it focusses light from a distant point in a dark room. A
170 ASTIGMATIC REFRACTION.
card held so as to intercept the pencil of refracted rays,
first at one and then at another distance from the lens,
shows the different forms the pencil assumes; and
shutting off part of the surface of the lens with colored
glass shows what part of the pencil the rays coming
through that part of the lens occupy.
The focussing of light by the astigmatic eye is also
illustrated by Fig. 66 in which VV represents the meri-
dian of greatest, and HH the meridian of least curvature.
Vertically, in the direction of W, all the rays above and
below are turned down and up so much that they are
brought to the level of the central ray at F. But hori-
zontally, in the direction of HH, they are not turned in
so much by the weaker curve, and do not come into line
with the central ray until they reach G. The rays are
converged in both* directions, but unequally, so that at F,
being all gathered to the same level but still spread out
laterally, they form a horizontal focal line FF. Then
they begin to spread out up and down, although stiil
gathering together from the sides, until at G they are
collected in the vertical focal line GG. Beyond G they
spread out in all directions. FF is called the anterior
focal line, and GG the posterior focal line. The distance
between the focal lines is the focal interval of Sturm.
The greater the difference between the curvatures of
FFand HH, the greater will be the focal interval, the
longer the focal lines, and the higher the degree of astig-
matism. The degree of astigmatism is expressed by the
difference in the refractive power of the eye in the two
principal meridians. It is corrected by the cylindrical
lens, which brings the two focal lines together, making
them a single point. It may be a convex cylinder, placed
so that its curve will help the weaker curve of the cornea,
which will bring the posterior focal line forward to the
anterior; or it may be a concave cylinder placed so that
its curve will partly neutralize the stronger curve of the
cornea, and thus carry the anterior back to the posterior
focal line. It Avill be noticed that the horizontal focal
line has its position fixed by the vertical curve of the
ASTIGMATISM AND CYLINDRICAL LENSES. 171
cornea, and that the vertical focal line has its position
fixed by the horizontal curve of the cornea. To help the
horizontal curve of the cornea the curve of the lens must
be horizontal and its axis vertical, and to neutralize the
vertical curve the curve of the lens must be vertical and
its axis horizontal. The curve of the lens being applied
to a certain curve of the eye, the axis of the lens at right
angles to that curve has the direction of the focal line
which the lens affects.
Appearance of Lines. — Astigmatism affects the seeing
of lines in this way. One of the focal lines is the nearest
to a focus that rays are brought by the astigmatic eye —
the anterior focal line being a little the shorter of the
two. ' When one of these focal lines is brought on the
retina, as it usually can be by the accommodation, lines
looked at which run in the same direction as the focal
line will be seen clearly, but all other lines will be
blurred. Each point of a line makes the impression of
a focal line on the retina. If these impressions overlap,
they reinforce each other, and make the strong distinct
impression of a single line. But if these impressions,
instead of overlapping each other, overlap the impressions
made by other points at the sides of the lines, they are
weakened so as to cause a blur.
This is illustrated in Fig. 67, in which A shows parallel
FIG. 67.— Appearance of lines running in different directions : A, as seen by
the normal eye ; B, as seen by the astigmatic eye,
lines as they appear to the eye free from astigmatism,
each point of the line making its impression on a single
point of the retina, and not overlapping in any direction.
172 APPEARANCE OF LINES.
R represents the appearance these lines present to an astig-
matic eye with the vertical focal line falling on the
retina, each point making the impression of a vertical
line. For the vertical lines the impressions overlapping
one another make the lines sharp except at the ends, which
are blurred. But for the horizontal line the vertical over-
lapping runs them together, making a broad blurred band
with distinct ends.
Causes and Seat. — Astigmatism is commonly due to
a congenital anomalous development of the cornea. Some-
times the asymmetry of the cornea! curvature develops
during childhood or in adult life. It may be produced
by extensive corneal wounds, as that made for cataract-
extraction, in which case the cornea is flattened in the
meridian perpendicular to the corneal incision. It may
be produced by* cicatricial changes following corneal
ulcers, or by the bulging of the conical cornea. In most
eyes the difference between the corneal astigmatism as
measured by the ophthalmometer, and the total or net
astigmatism of the eye as measured by skiascopy or the
test lenses, shows that the crystalline lens also takes part
in the causation of astigmatism. Usually the lens-astig-
matism partly neutralizes that of the cornea, the net
astigmatism of the eye being less than that of the cornea
alone, yet in some eyes the lens-astigmatism greatly pre-
dominates. Lens-astigmatism may be due to asymmetry
of the lens-surfaces, or to their being placed obliquely
with regard to the rays entering the pupil.
Varieties. — Astigmatism is always ametropia of
curvature, its direction and amount being entirely inde-
pendent of the position of the retina. Still its recognized
clinical varieties are based on the various positions of the
retina with reference to its focal lines. These are five in
number. They are illustrated in Fig. 68, in which F
represents the anterior and G the posterior focal line.
The retina may be in front of both focal lines as at (1)
the eye hyperopic in both principal meridians ; this is
called compound hyperopic astigmatism. The retina may
pass through the anterior focal line (2), the eye being
ASTIGMATISM AND CYLINDRICAL LENSES. 173
hyperopic for the meridian of least curvature and emme-
tropic for the other ; this is simple hyperopic astigmatism.
The retina may lie between the focal lines (3), the eye
being still hyperopic for the meridian of least curvature,
but myopic for the meridian of greatest curvature — mixed
)M
FIG. 68.— Different positions of the retina with reference to the focal lines:
1, compound hyperopic ; 2, simple hyperopic ; 3, mixed astigmatism ; 4, simple
myopic ; 5, compound myopic.
astigmatism. The retina may pass through the posterior
focal line (4), the eye being myopic for the meridian of
greatest curvature and emmetropic for the meridian of
least curvature — simple myopic astigmatism. The retina
may lie beyond the posterior focal line (5), making the
eye myopic for both meridians — compound myopic astig-
matism.
By elongation of the eyeball, such as produces myopia,
the same eye may pass from compound hyperopic to com-
pound myopic astigmatism through all the intermediate
varieties, without material change in the direction or
curvature of the principal meridians, and without change
in the amount of the astigmatism.
Symptoms. — Astigmatism of high degree always
diminishes actiteness of vision, both distant and near.
The extent to which it does this depends on the degree
of the astigmatism, the size of the pupil, and the ability
of the patient to piece together and interpret partial
retinal images ; for the astigmatic eye can often by a cer-
tain amount of accommodation bring one focal line on the
retina, so that certain lines are seen clearly, and then by
another amount of accommodation it can bring the other
focal line on the retina, and see other lines clearly. The
mental ability to combine and utilize the partial impres-
174 SYMPTOMS.
sions so obtained will greatly influence the patient's
response to the ordinary tests of visual acuteness.
Normal acuteness of vision by the usual standard may
be possessed by eyes so astigmatic as to cause serious
eye-strain. It is by eye-strain that low degrees of astig-
matism manifest their existence. The symptoms depend
on the requirements made of the eyes in the way of close
work, and the endurance of the nervous system and
ocular tissues, as determined by the state of the general
health.
The liability to headache, its character, and amenability
to other treatment are much the same with astigmatism
as with other forms of ametropia. Astigmatism causes
the same congestion, or chronic or recurring inflammation
of the conjunctiva and lid-margins. It is a very impor-
tant cause of the*choroidal changes that accompany and
probably aid in causing myopia. Many cases pass, as
Risley says, from hyperopia to myopia " through the turn-
stile of astigmatism.'' The symptoms of astigmatism
may vary with the amount of effort required of the eyes,
or they may be more apparently connected with varia-
tions in the general health.
Diagnosis. — Impairment of vision is always present
with astigmatism of high degree, but it is less than for
the same degree of hyperopia or myopia. It affects dis-
tant and near vision about equally. The patient usually
recognizes some letters better than others, miscalling
some letters in one line, and reading others correctly that
are two or three lines smaller. The near-point is about
where it would be for emmetropia at the patient's age,
unless there is also hyperopia or myopia to affect it. With
the special test-cards of radiating lines, the lines running
in some one direction (usually the direction of the pos-
terior focal line if accommodation is good) are seen more
clearly than others ; but sometimes a patient will deny
that the lines are clearer in any one direction, or will give
contradictory answers.
On looking at a point of light the astigmatic eye may
see it as a line of light, the lens indicating the direction
ASTIGMATISM AND CYLINDRICAL LENSES. 175
of one of the principal meridians. This is made the
basis of certain tests for astigmatism, but if the pupil is
dilated, the line significant of regular astigmatism is in
many eyes masked by the radiating lines due to irregular
astigmatism. Hotz's astigmometer* and Thomson's ame-
trometer are based on this distortion of a point of light
as seen with an astigmatic eye.
In the trial case will be found a metal disk with a nar-
row slit in it, the stenopaic slit. If this be placed before
an astigmatic eye and turned in various directions, it is
found that a. certain direction gives the best vision, and
that at right angles to this the vision is worst. The
former direction is that of the least ametropic curve;
the latter direction is that of the most ametropic curve.
The slit being placed in one of these directions, the
spherical lens which most improves the vision is the lens
which corrects that principal meridian. When both
FIG. 69.— Radiating lines test for astigmatism.
meridians have thus been tested, the difference between
the two is the amount of astigmatism.
Difference in the distinctness of lines running in differ-
ent directions may be detected by looking at such a
J76 DIAGNOSIS OF ASTIGMATISM.
figure as is shown in Fig. 69. If difference of clearness
in the radiating lines is noticed, three parallel lines, small
enough to be just distinguishable at the distance at which
they are placed, may be turned in different directions,
and that direction noted in which they appear clearest.
By trial the spherical lens is then found which renders
the lines most distinct in that direction. It is the meas-
ure of the ametropia in the meridian at right angles to
the lines. The lines are then turned 90 degrees, and the
lens found which renders them most clear in that direc-
tion. The difference between the two lenses measures
the astigmatism.
If either of the above tests are applied to an eye
which has power of accommodation, the strongest convex
or weakest concave lens which fulfils the necessary con-
ditions is the o\je to be aimed at. Thus, the strongest
convex or weakest concave lens that leaves the line of
light will fix its direction most definitely with the Hotz
or Thomson instruments. The strongest convex or weak-
est concave lens that gives the best vision with the
stenopaic slit, or renders the parallel lines most distinct,
is the one which most nearly indicates the ametropia in
the corresponding meridian.
The above subjective tests are of value for discovering
and approximately measuring astigmatism. The objective
methods of approximately estimating astigmatism are, by
the refraction ophthalmoscope, by measuring the corneal
astigmatism with the ophthalmometer, and by skiaseopy.
The value of the ophthalmoscope in the diagnosis of
astigmatism depends on the fact that a pencil of rays
emerging through an astigmatic cornea is rendered astig-
matic, so that it forms on the retina of the surgeon, not a
point but a focal line. Such focal lines enable the sur-
geon to see clearly those lines in the patient's retina which
run parallel to them, while all others are blurred. Thus,
if a vertical focal line falls on the surgeon's retina, he
sees clearly the parts of the patient's retinal vessels which
run vertically, or the vertical sides of the patient's optic;
disk ; but all other parts of the retinal vessels, and all
ASTIGMATISM AND CYLINDRICAL LENSES. 177
other parts of the outline of the optic disk appear blurred,
the parts that run horizontally being most blurred. The
peculiar appearance of the fundus in a highly astigmatic
eye is best reproduced by looking through a + 6. D.
cylindrical lens at a picture of the normal fundus (Plate I.)
held at a distance of 10 or 12 inches.
The direction in which the lines appear most clear is
the direction of one of the principal meridians of astigma-
tism. It is most accurately determined with the strongest
Fio. 70. — .laviil-Sehiotz ophthalmometer.
convex or weakest concave lens that leaves the vessels
clear in any one direction ; that lens also measures the
ametropia in that meridian. The other principal meri-
dian is at right angles to the first, and the strongest
convex or weakest concave lens that renders the vessels
clear in that direction measures its ametropia. The
difference between the two gives the astigmatism.
12
178 THE OPHTHALMOMETER.
The ophthalmometer measures the curvature of the
cornea by the si/e of the reflection it gives of a known
object. The instrument of Javal and Schidtz lias had
most general clinical use. It is illustrated in Fig. 70
and is now alone alluded to. In it the test-object is the
distance between the two "mires" MM which are movable
on the arm A, which revolves in front of the large disk
I). This object is placed a fixed distance from the
patient's eye, the distance at which the telescope BE,
through which the surgeon looks, focusses the reflection
from the patient's cornea, so that both it and the cross-
hairs fixed in the body of the telescope are seen clearly.
The size of the reflection is fixed by the strength of a
" doubling prism" behind the object-glass of the telescope,
a reflection of the proper size being secured when the two
adjoining images^of the mires, as seen through the tele-
scope, appear to touch. They are made to touch by
moving one of the mires ; and when tbey touch, the posi-
tion of an index on the mire indicates on the arm the
radius of curvature of the cornea in millimeters, and the
refraction of the eye in that meridian in diopters.
To use the instrument the disk and mires must
be strongly illuminated. The patient, with his brow
applied to the head-rest H and his chin on C, looks
with the eye to be measured into the telescope, the
other eye being covered. The surgeon, looking through
the telescope from E, directs it so that the adjoining
A B
FIG. 71. — Mires of the ophthalmometer: A, with the arm not corresponding
to either principal meridian of the cornea ; B, turned to one of the principal
meridians.
images of the two mires come to the center of the
field. If the black lines across the two mires do not
ASTIGMATISM AND CYLINDRICAL LENSES. 179
appear continuous as in Fig. 71 A, the arm is not parallel
to either of the principal meridians of the cornea. It
must first be made parallel to one of these meridians and
the lines continuous, as at B, by revolving the body of
the telescope. When the arm corresponds to one of the
principal meridians, the movable mire must be shifted
till its reflection just touches that of the fixed mire, as at
(7 in Fig. 72. The arm is then rotated to the other
principal meridian. If the mires overlap as at D, Fig. 72,
r>
FIG. 72.— Mires of the ophthalmorneter: C, in the meridian of least refrac-
tion, just touching; D, in the meridian of greatest refraction, overlapping for
1.75 D. of astigmatism.
the number of steps of overlapping shows the number of
diopters of astigmatism. If the mires separate, as .at B
in Fig. 71, the movable mire must be shifted until it
touches the other, and the arm then rotated back to the
first principal meridian, when the overlapping will indi-
cate the astigmatism. The overlapping occurs in the
meridian of greatest curvature, the vertical meridian in
astigmatism with the rule.
Reid's ophthalmometer is a practical instrument, and
being but little larger than an ophthalmoscope is readily
carried and used anywhere. In it the test-object is a
circular opening in the side of the telescope, the size of
which is varied by an iris diaphragm. The reflection of
this object from an astigmatic cornea is an ellipse, and
the sizes of the opening necessary to render the doubled
images of the ellipse just tangent, first in the direction of
the long axis, and then in the direction of the short axis,
indicate the ametropia in the principal meridians. The
difference between the two meridians gives the astigma-
180 THE OPHTHALMOMETER.
tism. The short axis of the ellipse corresponds to the
meridian of greater curvature of the cornea.
In a great many eyes the corneal astigmatism is about
0.5 D. greater than the total or net astigmatism of the
eye. This amount deducted from the corneal astigma-
tism when with the rule, or added to it when it is against
the rule, may be taken as the indication of the ophthal-
mometer. But it must always be remembered that the
difference between the corneal and the net astigmatism
may be very much greater, and that they may have their
principal meridians in totally different directions.
Skiascopy is by far the best objective method for
measuring astigmatism. The rays emerging from the astig-
matic eye when made to converge (by a convex lens when
the eye is not myopic) come together, not at a single
point but at twc*point£ of reversal, one for each principal
meridian. At each of these points of reversal the light
in the pupil assumes more or less the appearance of a
band, running in the direction of the principal meridian
to which the point of reversal belongs. This band-like
appearance is illustrated in Fig. 73. It is brought out
FIG. 73.— Band-like appearance in direction of principal meridian of greatest
curvature at 70°.
most distinctly when the source of light is a small circular
opening in the metal shade over the lamp-flame, this
source being so placed that the light enters the patient's
eye as if from the point of reversal of the other principal
meridian.
The movement and appearance of light in the pupil
ASTIGMATISM AND CYLINDRICAL LENSES. 181
from different distances (with the plane mirror) are as
follows : When closer to the patient's eye than the point
of reversal the surgeon sees the light moving " with " the
light on the face in all directions. As he draws back,
approaching that point of reversal which is the nearer to
the patient, the light is seen to move more swiftly in the
direction of the meridian to which that point of reversal
belongs, and to assume the appearance of a band running
in that direction. At the nearer point of reversal it can-
not be distinguished which way the light moves in the
direction of the band, but at right angles to its length
the band is readily made to move " with " the light on
the face. Withdrawing still farther from the patient, the
movement in the direction of the band is again distin-
guished, but it is now "against" the light on the face.
The movement still continues " with " the light on the
face in the other meridian. The band now rapidly
becomes indistinct, and half-way between the two points
of reversal not a trace of it remains. Here the appearance
of light in the pupil is precisely the same as in an eye free
from astigmatism, except that the light moves " with "
the light on the face in one meridian and "against" it in
the other. Still farther from the patient's eye the band
begins to be seen in the direction of the other principal
meridian, and the movement of light in that meridian,
still " with " the light on the face, becomes more rapid.
At the point of reversal for the meridian of least curva-
ture, the band is seen running in the direction of that
meridian. The movement in the direction of this band
is now indistinguishable, and the movement in the other
meridian is "against" that of the light on the face.
Withdrawing beyond this farther point of reversal the
movement is found to be " against " the light on the face
in all directions, rapid at first in the direction of the last
band, but soon growing slower in all directions.
To illustrate the use of skiascopy, let us suppose an eye
requiring a correction of + 1. sph. O + 1. cyl. ax. 90°, to
be examined with the plane mirror. The surgeon sits
two or three feet in front of the patient with the mirror
182 SKTASCOPY.
to his eye, and the light as close as possible to the mirror.
Reflecting the light on the patient's eye the light in the
pupil is found to move " with" the light on the face in
all directions ; and because the light in the pupil moves
rather slowly, it is known that considerable lens-strength
will be needed to bring a point of reversal to the surgeon's
eye.
A + 3. D. sph. is placed before the eye. With this the
movement is "against" the light on the face up and down,
but still " with " it from side to side. This shows astig-
matism. The surgeon then leans toward the patient and
at 0.5 meter (20 inches) from the patient's eye the verti-
cal movement " against " is replaced by a vertical band,
in the direction of which the movement is indistinguish-
able. This band moves from side to side " with " the
mirror. This, tlfcn, is the nearer point of reversal. To
fix most accurately its direction, while keeping the observ-
ing eye at 20 inches from the patient's, the light is pushed
away from the mirror until, when it is 20 inches from the
mirror, the band becomes most distinct, the light now
being reflected from the mirror as if it came from a point
40 inches away — the farther point of reversal. Under
these circumstances the band from 1. D. of astigmatism
may be quite as distinct as that shown in Fig. 73.
Having thus determined one principal meridian, the
other (being always at right angles to it) is also known.
The point of reversal is then carefully determined by
bringing the light as close as possible to the mirror, and
getting the movement in the vertical meridian alternately
" with " and " against," noting where it changes from one
to the other. Its distance from the eye is then measured,
20 inches, corresponding to 2. D. of myopia. As the
3. D. lens causes 2. D. of M., there must have been
3 — 2 = 1. D. of hyperopia in this meridian. The other
point of reversal is then determined in the same way.
In this case it is found to be at 40 inches or one meter
. from the eye ; indicating that the lens used causes 1 . D.
of myopia in this meridian, and that without the lens
there is 3 — 1 -~ 2. D. of hyperopia in the meridian of least
ASTIGMATISM AND CYLINDRICAL LENSES. 183
curvature. The difference betwee.ii the two meridians, or
1. D., is the amount of astigmatism.
To confirm the results obtained by skiascopy it is
always best to place before the eye the cylinder that is
expected to correct the astigmatism, and repeat the test
to see if it really does so. Thus, in the above case,
placing a + 1. D. cyl. ax. 90° before the eye, the point
of reversal will be found at 20 inches for all meridians ;
on placing a —1. D. cyl. ax. 180° before the eye, the
point of reversal will be found at 40 inches for all
meridians.
When the astigmatism is low (0.5 D. or less), it may
be impossible to bring out a band of light in the pupil.
But it can be noticed that the movement becomes indis-
tinguishable, or reverses sooner in one direction than in
others ; and this proves the existence, and indicates the
meridians of the astigmatism.
The test-lenses have been called the court of last
appeal in the diagnosis of errors of refraction. But in
this connection it should be remembered that the real
value of the decision of a court of last appeal rests on its
opportunity to review all the arguments and decisions
that have gone before. The accuracy of the result
obtained with the test-lenses depends largely on the
knowledge of the refraction previously acquired by skias-
copy and other methods. If one cannot use skiascopy
and has no ophthalmometer, the stenopaic slit or the
parallel lines with spherical lenses can give very valuable
assistance in the diagnosis of astigmatism.
The trial with the test-lenses should begin by placing
in the trial-frames, before the eye, the correcting lenses,
as these have been determined by other methods. When
the patient has read the test-letters as far as he can with
these, they are to be modified by holding in front of them
supplementary lenses. First + 0.50 and — 0.50 spherical,
may be alternated unless the vision is still quite poor,
when + 1. and — 1. D. should be used. If either of these
improves vision, a corresponding change is to be made in
the lens in the trial-frame ; and the trial with supple-
184 TRIAL-LENSES.
mentary lenses repeated until any change in the spherical
makes vision worse.
Then the direction of the cylinder may be tested by
turning it first to the right then to the left, and asking
the patient to say " stop," as soon as the change begins to
make vision worse. The points on each side, at which
vision is rendered perceptibly worse, must be carefully
noted in repeated trials, and a point half-way between
them is the proper direction for the axis of the cylinder.
To test the strength of the cylinder the astigmatic lens
should be used. This is a crossed cylinder, or an equiva-
lent sphero-cylindrical lens, convex in one meridian and
equally concave in the meridian at right angles to that.
The most useful combination is — 0.25 sph. o + 0-50
cyl., but a lens of double that strength and one of half
that strength are gflso useful. The astigmatic lens is used as
a supplementary lens, the axis of the cylinder being first
held in the same direction as the axis of the cylinder in
the trial-frame, and then turned perpendicular to it. In
one position it adds to the effect of the cylinder in the
trial-frame ; in the other it diminishes that effect. The
patient is asked which way is the better, or whether one
way is any better than the other. If it makes no differ-
ence which way the astigmatic lens is turned, the cylinder
already in the trial-frame is of the right strength. If
the astigmatic lens does make it better in one direction
than the other, the cylinder in the trial-frame is to be
changed according to that indication.
After this the strength of the spherical is again to be
tested, in connection with the new cylinder, and the direc-
tion of its axis must be re-tested ; this process must con-
tinue until any change in the lenses makes vision worse.
The testing should be interrupted to let the patient rest
whenever he becomes tired, otherwise his answers become
unreliable. When there is any discrepancy between the
results of skiascopy and the test-lenses, it may be well to
repeat skiascopy, and, after the eye has recovered from
mydriasis, to try it with the lenses again.
Treatment. — Astigmatism, when it requires treat-
ASTIGMATISM AND CYLINDRICAL LENSES. 185
ment, demands the constant use of correcting lenses. Low
degrees do not materially impair the acuteness of vision,
and if the eyes are not used much, and no sign of eye-
strain arises, nothing need be done for it. When, how-
ever, glasses have to be worn for hyperopia or myopia, if
any astigmatism is present, even 0.25 D., it is usually
better to correct it.
Since any case of astigmatism can be corrected by
either a convex cylinder with its curve in the direction of
the less curved meridian, or a concave cylinder with its
curve to the more curved meridian, there is always a
chance to choose between two combinations. It has been
customary to correct hyperopic astigmatism with a convex,
and myopic astigmatism with a concave cylinder, thus :
+ 1. sph. o + l. cyl. ax. 90°.
But
+ 2. sph. o-l. cyl. ax. 180°
is equally effective. It will be noticed that the first re-
quires the use of a weaker spherical than the second ; but
the second, having one concave and one convex side, if
mounted with the former toward the eye, gives the advan-
tage of a periscopic lens.
Any case of astigmatism can be corrected by crossed
cylinders, as thus for the above case :
+ 1. cyl. ax. 180° C + 2. cyl. ax. 90°.
But such lenses cannot be ground with perfect accuracy,
and are far more expensive, while they offer no advantage
over the periscopic formula.
In general, the full correcting cylinder is ordered, in
conjunction with the needed spherical for any use. But
when a strong lens is looked through obliquely, its
strength is so increased that the full correcting lens might
be too strong. It is therefore better to deduct 0.25 or
0.50 D. from very strong cylinders that will have to be
looked through obliquely. It should be borne in mind
also that when a strong spherical is looked through
obliquely it has the effect of a sphero-cylinder (see p. 191).
186 ASTIGMATISM.
Prognosis. — As a rule, astigmatism changes but little
throughout life. In some cases, however, it changes very
markedly. It is especially liable to change in rapidly
growing children, and at about the age of fifty ; and
generally in eyes that are rapidly becoming less hyperopic
or more myopic. After cataract extraction, or other cor-
neal injury, the resulting astigmatism reaches its height
in a few days after the complete closure of the corneal
wound, and then slowly subsides, the permanent condi-
tion not being reached sometimes for several months.
ABERRATION.
The cornea is always more curved at its center and
flattened toward its periphery. The crystalline lens is
flatter at the center and more convex at its periphery.
These usually balance each other near the center of the
pupil, causing an area, the visual zone, the refraction of
which usually compares well with that of artificial opti-
cal instruments. But at the periphery of the dilated
pupil, either the flattening or the increased curvature
predominates, causing aberration.
If the increased curvature predominates, so that the
eye is more myopic or less hyperopic at the edge of the
pupil than at the center, it is called positive aberration.
This resembles the aberration of a spherical lens. It is
the more common form. If the flattening predominates
at the edge of the pupil, making it less myopic or more
hyperopic than at the center, it is called negative aberra-
tion. The difference between the refraction of the center
of the pupil and that of the margin often amounts to
1. D. or over.
Aberration interferes with the measurement of ame-
tropia. It is, next to accommodation, the most serious
obstacle to accurate measurements with the refraction
ophthalmoscope, and makes it necessary in skiascopy
to come near the patient, to get the movement of light
and shade in the visual zone at the center of the pupil,
which may be directly opposite to the movement at the
ABERRATION. 187
edge of the pupil. These two areas of light that it causes-
in the pupil are shown in Fig. 74.
In exceptional cases it causes the patient to select
under a mydriatic a lens which will not suit him when
A B
PIG. 74. — Appearance of the pupil in aberration : A, from near the point of
reversal for the extra-visual zone near the margin of the pupil ; B, from near
the point of reversal of the visual zone at the center of the pupil.
the pupil has contracted. With negative aberration he
may choose under a mydriatic a convex lens too strong to
allow of clear distant vision when the mydriatic has
passed off. The aberration should be examined by skias-
copy in each case of refractive error. The cases of
greatest aberration (negative) are those of conical cornea,
in which the apex of the cone may be 20. or 30. D.
myopic, while the periphery of the pupil is even hyper-
opic. Aberration, usually negative, also appears as the
result of the lens-changes preceding cataract.
IRREGULAR ASTIGMATISM.
Irregular astigmatism exists in all eyes. Usually it is
confined to the periphery of the dilated pupil ; but often
a low degree of it may be detected, by skiascopy, at the
center of the pupil. The term includes interference with
refraction caused by all irregularities of the cornea or
crystalline lens. Typical forms are caused by the altera-
tions in the cornea that follow keratitis, and by the
changes in the crystalline lens that precede senile cataract.
It causes impairment of vision, and interferes with the
188 IRREGULAR ASTIGMATISM.
various tests for ametropia. It may also cause monocular
polyopia, multiple images of objects, especially of the
moon or sources of artificial light, by reason of different
parts of the cornea or lens forming each its separate
image on the retina. The parts of the pupil which form
the particular images can be ascertained by noticing the
effect of covering particular portions of the pupil. What
has been called normal irregular astigmatism by Donders
is partly aberration. It causes, when the pupil is dilated
by darkness, the rays which most eyes see, extending from
a point of light, as a star or distant arc light.
Irregular astigmatism cannot be corrected by any lens.
Narrowing of the pupil diminishes its effect. Spectacles
with an opaque disk having a small opening, or a narrow
slit in it, called stenopaic spectacles, sometimes improve
vision. But they*can rarely be worn, because they limit
the field of vision so much. Often there is with high
irregular astigmatism some small part of the cornea
presenting regular astigmatism, hyperopia, or myopia,
the correction of which will give the patient greatly
improved vision. Such areas should be carefully sought
for and corrected.
ANISOMETROPIA.
Anisometropia, or inequality in the refraction of the
two eyes, exists in slight degree in a very large propor-
tion of cases. The term is usually applied only to cases
presenting great differences between the two eyes, or
when one eye is hyperopic, and the other myopic, for
which state antimetropia is also used. If the difference
of refraction is small — 1. D. or less — each eye is given its
correcting lens. This plan can often be followed until
the difference amounts to 2. or 2.5 D., although in these
cases it is sometimes better to weaken slightly the
stronger of the two lenses. When the difference is
greater than 2.5 D., each eye may be given its correcting
lens in some cases ; but sometimes it is best to give the
correcting lens for the better eye, and one of about the
same strength for the other.
ERRORS OF REFRACTION. 189
THE MOUNTING AND WEARING OF GLASSES.
Lenses, to be of service, must be properly mounted
and worn. Spectacle frames are superior to eye-glasses
(pince-nez) for strong cylinders ; the former generally can
be more accurately adjusted, and keep their place better.
Eye-glasses, however, because of their appearance, will
sometimes be worn when spectacles would not. They are
more convenient for slipping on and off, if this must
frequently be done, as with glasses used for presbyopia.
In any frame the lenses must be mounted so as to take
their proper position before the eyes. They must have the
proper distance between their centers (usually the pupil-
lary distance) ; and must stay permanently at the proper
height, not slip down because the nose-piece is too high.
They must be the proper distance before the eyes, usually
just far enough away to escape being touched by the
lashes ; and they must have such an inclination that
when in use the eyes will look as nearly perpendicular to
the surfaces of the glass as possible — that is, for distance
the glass should face directly forward ; for near-seeing
they should face somewhat downward.
Effects of Oblique I/enses. — "With strong lenses it
is very important to have the line of sight nearly perpen-
dicular to the lens surfaces. When looked through
obliquely, the effect is that of a stronger lens to which has
been added a cylinder with its axis parallel to the line
about which the lens is rotated to make it oblique. Thus,
a 10 D. convex lens, rendered oblique by rotating it around
its horizontal axis, is changed according to the amount of
obliquity, to act as follows :
10 degrees as a -f 10.10 + 0.37 cy. axis 180°,
20 " " " + 10.40 + 1.38 cy. axis 180°,
30 " " " -h 10.93 + 3.65 cy. axis 180°,
40 " " " + 11.73 + 8.25 cy. axis 180°.
Patients sometimes look obliquely through the edge of
their glasses to get the effect of a stronger lens than has been
furnished them, or a cylindrical effect that their lenses do
not give. This expedient is not a good one, because when
the obliquity is sufficient to give a decided effect a slight
190 ADAPTATION TO GLASSES.
change of obliquity gives a marked change in that effect.
To prevent the undesirable effects of looking obliquely
through a lens, the periscopic form is to be adopted.
(See p. 115 and p. 185.) The ideal combinations for such
periscopic lenses are indicated in the following table :
SURFACES FOR PERISCOPIC LENSES.
Convex. Concave.
Lens Anterior Posterior Anterior Posterior
strength. surface. surface. surface. surface.
l.D.
2.D.
3.D.
4.D.
5.D.
10.D.
lo.D.
+ 6. D.
+ 8. D.
+ 10. D.
+ 12. D.
+ 13. D.
+ 21. D.
+ 27. D.
- 5. D.
— 6. D.
— 7. D.
— 8. D.
- 8. D.
— 11. D.
— 12. D.
+ 5.5. D.
+ 5. D.
+ 4.5. D.
+ 4. D.
+ 3.5. D.
Plane
Plane
- 6.5. D.
— 7. D.
— 7.5 D.
— 8. D.
— 8.5 D.
— 10. D.
— 15. D.
Changes with Age. — Beside the gradual increase
of presbyopia that usually occurs between 45 and 60
years of age, changes in refraction occur, apart from
injury or disease of the eyes, making occasional changes
in the correcting glasses advisable. In early childhood
the hyperopia, always present at birth, tends to diminish.
Myopia shows the greatest tendency to increase between
10 and 20 years of age, but high degrees of it may con-
tinue to increase throughout life. In most persons hy-
peropia increases during adult life, and myopia of low
degree often shows a tendency to diminish. Astigmia
may change in every respect, and in a large proportion of
persons there is a tendency to a shifting of its meridians,
so that in old age the meridian of greatest curvature is
apt to be horizontal or nearly so, astigmia against the
rule, while in childhood astigmia according to the rule is
much more common. (See page 169).
The Period of Adaptation. — Seeing through a pair of
new lenses demands a new co-ordination of the nervous
and muscular actions concerned in vision, which, like any
other new exercise, requires time to master. Until the
new actions have become customary and automatic, the
best help will not be obtained from the glasses. The
hyperope may have trouble in relaxing his accommoda-
ERRORS OF REFRACTION. 191
tion so as to lot the glass do the work. The myope may
at first find it an effort to keep tip the accommodation
needed for near-seeing. Lenses of unequal strength, for
correcting nnsymmetrical astigmatism, cause apparent
distortion of objects (binocular metamorphopsia) and con-
fusion of perspective, that may not wholly disappear for
many months.
If the new lenses correct a considerable degree of
refractive error, previously unconnected, the patient should
be informed that they will not be entirely comfortable at
first. The necessary period of adaptation will be some-
what proportioned to the patient's age, varying from a day
or two in children, to two or three months or even longer
in old people. If the patient be not informed of these
difficulties at the time of getting his glasses, he will think
that there has been some mistake about them, and may
meet subsequent explanations with incredulity.
CHAPTER VIII.
DISORDERS OF THE OCULAR MOVEMENTS.
MOVEMENTS of the eyeball are required to place the
most sensitive part of the retina where it will receive the
image of the object especially looked at; to keep the
eye turned in the desired direction, during movements of
the head and body that would otherwise displace it ; and
to keep the two eyes directed toward the same point, to
secure images which by fusion will give binocular vision.
There may be inability to execute these movements, or
they may be accomplished, but by undue effort.
If an eye is so directed that the image of the point on
which attention is fixed falls upon the fovea, the eye is
said to fix that point. Normally, both eyes " fix " the
same point. If, however, one of them does not fix the
point looked at, but has its visual line directed elsewhere,
192 FIXATION AND SQUINT.
it is said to deviate. Such an eye is called a deviating eye,
the other is called a fixing eye. The point " fixed " is
called the point of fixation, the angle between the deviat-
ing position of the visual line and its normal direction
through the point of fixation is the angle or degree of
squint. An eye which deviates is said to squint. The
deviation constitutes the abnormal condition of squint or
strabismus.
Ocular Movements. — The normal extent of the
ocular movements varies with the general muscular
power, and with the form and prominence of the eye-
balls and their relations to the orbit. The eyes can gen-
erally be turned from forty-five degrees to fifty-five
degrees to either the right or the left, a total excursion
horizontally of ninety degrees to one hundred degrees,
and they are capable of a total vertical movement of
seventy-five degrees to one hundred degrees. These move-
ments carry the eye outward until the outer margin of
the cornea is behind the external canthus, inward until
the inner corneal margin touches the plica and caruncle,
and up or down to where the margin of the cornea passes
considerably behind the widely opened lids. As the
limits of movement in any direction are reached, the
effort becomes fatiguing or painful, and the eye tends to
oscillate, exhibiting a kind of normal nystagmus.
Although the eyes are commonly so directed that their
visual lines meet in the point looked at, and their move-
ments are so co-ordinated as to preserve this relation con-
. stantly, it is a relation that can be changed within certain
limits. Thus, the visual lines commonly lie in the same
plane, passed through the fovea of each eye and the point
fixed. But one eye may be made to turn up or down more
than the other. It will do so to prevent double vision,
if a prism be placed before one eye with its base down or
up. The power of doing this is called the power of
sursumduction or sursumvergence. It varies normally
from one to two degrees — that is, double vision does not
occur unless the prism used thus is as strong as 2 to
4 centrads. The eyes are said to overcome weaker
DISORDERS OF OCULAR MOVEMENTS. 193
prisms by their power of sursu induction. If prisms be
placed before one or both eyes with their bases toward
the nose, the eyes looking at a distant object turn out
and their visual lines diverge, to "overcome" the prisms
and avoid double vision. This is called abduction or
prism-divergence. Its normal extent is about 5 to 10
centrads. When prisms are placed before the eyes with
their bases toward the temple the eyes turn in to " over-
come " them. This is the adduction or prism-convergence.
Its normal limits are from 12 to 20 centrads. The
normal relation of abduction to adduction power is 1 to
2 or 1 to 3. The adduction power may be increased by
practice ; and by using accommodation and rendering the
distant object indistinct, the eyes can be converged very
much more. But this is not what is usually meant by
the power of adduction. By a maximum effort the
visual lines may be caused to converge to the extent of
100 to 150 centrads (60 degrees to 85 degrees), so that
they will meet at a point even less than 3 inches from
the eyes. This power of converging the eyes is called
the power of convergence. It can be measured by the
nearest point at which an object can be seen single, the
near-point of convergence; or by the power to "overcome"
prisms with their bases toward the temple, if the patient
has learned to exert his full power in this way.
THE METER-ANGLE.
When the eyes look at a point directly in front of
them, and one meter away from each eye — that is, when
both visual lines meet one meter from each eye —
in the perpendicular to the line joining the centers
of rotation of the two eyes at its middle, the angle
which each visual line will make with this perpendic-
ular is called a meter-angle. Thus, in Fig. 75 : Sup-
pose R and L to represent the centers of rotation of the
two eyes, and P M the perpendicular to the middle
point of the line joining H and L. When the distance
R M or L M is 1 meter, the angle R M P or the angle
13
194 THE METER-ANGLE.
L M P is one meter-angle. If the distance from the eye
to the point fixed, as R Mf, is \ meter, the angle R M' P
equals two meter-angles. If the distance of the point fixed
is ^ of a meter, the angle equals three meter-angles, and so
for other distances. The number of meter-angles of con-
vergence has the same relation to the distance of the
point fixed as the strength of a lens in diopters has to
FIG. 75.— The meter-angle.
the focal distance of the lens. The value of the meter-
angle in centrads or degrees varies with the distance
between the centers of the two eyes. Thus, if the dis-
tance between the centers of rotation (regarded in practice
as equal to the distance between the centers of the pupils)
be 50 mm., the meter-angle equals 2.5 centrads or 1.43
degrees; for 60 mm. it is 3 centrads or 1.72 degrees, and
for 70 mm. it is 3.5 centrads or 2.005 degrees.
PROJECTION AND DIPLOPIA.
The image of an object is formed on the retina at the
point where a straight line from the object, through the
nodal point of the eye, pierces the retina. Conversely,
when an image is formed on the retina, the object from
which light comes to form it is referred or " projected "
in the direction of the straight line from that point of the
retina, through the nodal point of the eye. These " pro-
jections" of the impressions made on the retina by
external objects become by experience intimately asso-
ciated with impressions made through other senses, and
with them serve to locate the objects.
DISORDERS OF OCULAR MOVEMENTS. 195
When the two eyes are fixed on the same point, its
image falls on both foveas. These are corresponding
points. For any other point of the retina, the line of
projection from which makes a certain angle with the
visual line of that eye, there is a point in the other retina
from which the line of projection has the same relation to
the visual line of that eye. Such points are also corres-
ponding points. When the two eyes are fixed on a cer-
tain point, impressions of the point fixed, and of certain
other points, fall on " corresponding points " of the two
retinas. These points, whose images fall on corresponding
points of the retinas, constitute a surface called the
horopter. Only points lying on the horopter can make
their impressions on exactly corresponding points of the
two retinas. All points lying nearer to the eyes than the
horopter, or lying beyond it, make their impressions
on parts of the retina that do not exactly correspond.
Impressions of an object made in the two eyes on corres-
ponding points of the retina give rise to a single percep-
tion of the object.
If the points of the two retinas almost correspond,
there still results a single impression ; but the stereoscopic
effect by which we judge the relative distance of objects
is added. If the points on which the impressions are
made in the two eyes differ too widely in their relation to
the visual line, instead of the stereoscopic effect there
results a confused perception. If the points differ a little
more widely yet, two separate perceptions of the object
arise, and are referred in different directions, as though
belonging to different objects. This perceiving of the
objects separately by the two eyes constitutes binocular
diplopia, or double vision.
Such diplopia is readily produced by placing a finger-
tip on the middle of the lower lid, just within the margin
of the orbit, and pressing slightly backward. Keeping
both eyes steadily open, and fixed on some prominent
object, a false image will be seen to separate from the
true one, as the pressure of tissues back into the orbit
causes the eye to rotate downward. The student should
196 PROJECTION AND DIPLOPIA.
try this experiment to get a better understanding of
certain points in regard to squint and diplopia.
The departure from exact correspondence between
the points on which the impressions are made in the
two eyes, necessary to cause diplopia, varies for dif-
ferent parts of the retina. At the fovea, where nor-
mally the impressions are always made at exactly
corresponding points, the slightest lack of correspondence
causes confusion, and is extremely annoying. On the
periphery of the retina, where there is generally a lack
of exact correspondence in the impressions, they may fall
on widely different points, yet diplopia may not be per-
ceived or will not be annoying. Separation of peripheral
impressions constantly occurs, and habitually passes un-
noticed. But it can be perceived and studied thus : Hold
two pencils in ff line with the nose, one 6 inches in front
of the face, the other 12 inches in front of it. On fixing
the eyes on the nearer pencil, the more distant one will
appear double, its image falling not on corresponding
parts of the two retinas, but on the nasal side of the fovea
in both. On fixing the eyes on the more distant pencil,
the nearer one will likewise appear double, its images
falling on the temporal portions of both retinas, instead
of corresponding points, which would be the temporal
side of one retina and the nasal side of the other. In
this experiment, as in all physiological use of the eyes,
the images at the foveas exactly correspond, hence the
diplopia is not annoying, but may be even difficult to
discover. When the fixation-point is also involved in
the lack of correspondence between the two retinal im-
pressions, the diplopia is obvious and annoying. It can-
not generally be ignored.
When a seeing eye, which previously has fixed nor-
mally with its fellow, begins to deviate, diplopia results,
and the variety of the diplopia varies with the direction
of the deviation. The eye which still fixes properly
receives the image of the object looked at upon its fovra ;
and projects it in its true direction — the true imac/c. The
deviating eye receives the impression on some other part
DISORDERS OF OCULAR MOVEMENTS. 197
of the retina and projects it in some other direction, as a
second object of the same kind — the false image. The
relation of these to one another can best be illustrated
thus : Suppose Fig. 76 to represent a case of convergent
squint in which R is the fixing and L the deviating eye.
In R, the image of 0, the point looked at, falls at the
fovea. But in L the image of 0 falls elsewhere at /.
FIG. 76.— The projection of the false image in squint.
Hence, the projection of the false image seen by L will
not correspond to the projection of the true image seen by
R, but will be in the direction of F, the line /' F
making with the visual line R O the same angle as / 0
makes with the visual line L 8.
It should be noted that if the deviating eye be turned
up, the impression of the object fixed is made on the
upper part of the retina, and the false image is projected
below the true image. If the deviating eye be turned to
the right, the impression is made on the right half of its
retina, and the false image is projected to the left of the
true image. In general, the false image is projected in a
direction from the true image, the opposite of that in
which the eye deviates.
When the image seen by the right eye appears to the
right, and that belonging to the left eye to the left, the
diplopia is called homonymous. When the image belong-
ing to the right eye is seen to the left, and that belonging
to the left eye appears more to the right, it is crossed
diplopia. Homonymous diplopia occurs when the eyes
are crossed, and crossed diplopia when the eyes diverge.
198 DIPLOPIA.
Diplopia is more annoying in proportion to the previous
perfection of binocular vision, the suddenness of its occur-
rence, the age of the patient, and the nearness of the false
image to the true image. Where the power of binocular
vision has never developed, as in patients affected with
squint from infancy, diplopia is never noticed, and it may
be impossible to provoke it. When the vision of one eye
is very imperfect, diplopia causes little annoyance. "With
high degrees of squint, too, diplopia is not troublesome,
because the false image falls so far from the fovca.
In squint of long standing, especially if developed in
childhood, the annoyance of diplopia is avoided by habit-
ually disregarding the impression made on the deviating
eye, much as one accustomed to the use of the ophthal-
moscope, microscope, or other monocular optical instru-
ment, learns to Disregard the visual impressions made on
his unused eye, and to work with both eyes open. Any
change in the position of the false image on the retina
is likely to make it more noticeable. This may be taken
advantage of in attempting to provoke diplopia. It
must also be remembered that where binocular fusion
is impossible, diplopia may be rendered very annoying by
bringing the image to the macula.
AMBLYOPIA WITH SQUINT.
In the majority of cases vision is poorer in the devia-
ting than in the fixing eye. This may be due to an error
of refraction, to noticeable defects within the eyeball, or to
congenital amblyopia. But often it is largely a conse-
quence of the squint — amblyopia ex anopsia. Visual
acuteness, and especially the power to recognize letters, is
developed by use, which the deviating eye does not get.
In some cases vision in the squinting eye actually deteri-
orates after squint is' established. This is ascribed to
habitual "suppression" of the image to prevent diplopia.
Causes Of Squint. — Congenital inability to turn the
eyes in certain directions is rare, but cases occur. It will
be referred to under Paralytic Squint. Incomplete power
of binocular co-ordination is much more common. This
DISORDERS OF OCULAR MOVEMENTS. 199
might be expected from the extremely complex character
of the adjustments required and the comparatively recent
evolution of the power of binocular vision. The general
causes of acquired squint are paralysis of one or more of
the ocular muscles ; and imperfect vision in one eye,
either from opacity of the media, distortion of its dioptric
surfaces, or disease of the choroid, retina, or optic nerve,
rendering it unable to participate in binocular vision.
Hyperopia, myopia, and other special causes will be con-
sidered with the particular forms of squint which they
occasion.
Diagnosis of Squint. — The evidence of squint is
often revealed by the most casual inspection of the eyes.
Still the most obvious appearance of squint may be mis-
leading. We "judge the direction of the eyes by the
direction of the cornea ; and when the visual line pierces
the cornea at the usual point a little to the nasal side of
the center, we can thus judge correctly. When, however,
the visual line pierces the cornea at a distance from its
center, the cornea will appear to be turned in one direc-
tion, while the visual line is really directed somewhere
else. The eye will appear to squint, when really both
eyes have their visual lines directed to the point fixed ;
or it will appear to be properly directed when really
squinting. The appearance of squint must therefore be
confirmed by careful tests.
The Cover-test. — If both eyes possess useful vision,
the covering of the squinting eye compels the patient to
" fix " with what was previously the deviating eye. This
he may do by turning the head, in a case of paralytic
squint, or by simply turning the eyes in a case of comi-
tant squint. The eye which had previously deviated
turns, so as to fix the point at which the patient is trying
to look ; and the eye that had fixed turns elsewhere —
deviates. Thus, by covering the fixing eye, the deviation
or squint is transferred from one eye to the other. By
shifting the cover from one eye to the other the squint is
transferred back and forth. The cover, which may be
the hand or a piece of cardboard, held in front of the
eye, should be far enough in front to allow7 the surgeon to
200 DIAGNOSIS OF SQUINT.
watch the movement that occurs behind it ; but it must
be so held as certainly to interrupt the patient's view
with the covered eye.
The direction from which the eyes move when the
cover is shifted indicates the direction of the squint.
Thus, if on uncovering the right eye, it moves to the
right to fix the object, it must have been deviating to the
left — convergent squint; if it moves upward, it was
deviating downward — vertical squint ; if it moves to the
left, it was deviating to the right — divergent squint.
Power of Moving Eyes in Different Directions. —
Having ascertained that squint is actually present, we
must next determine is it comitant (concomitant) squint
or paralytic squint. This may be done by watching the
behavior of the eyes when they attempt to. fix an object
held successively in different directions. The patient
may be directed to fix continuously the end of a finger or
a lead pencil, which the surgeon holds first in one part
of the field and then in another. If the squint be
comitant, it remains substantially the same, whatever the
direction in which the eyes are turned. If, however, the
squint be due to the weakness or paralysis of some par-
ticular muscle or muscles, the eyes move and fix normally
together, so long as the affected muscle or muscles are not
called upon. But when the contraction of the affected
muscle is necessary for the movement required of one of
the eyes, that eye will lag behind its fellow, will no
longer fix the object, but will deviate ; and the stronger
the contraction required of the paralyzed muscle the
greater the deviation. The direction of the movement
which the squinting eye fails to execute shows which
muscle is affected. Thus, if the right eye fails to turn
upward with the left, the right superior rectus is at fault ;
if it fails to turn to the right, the right external rectus
does not properly perform its function ; if it lags on look-
ing down, the inferior rectus ; on turning the eye to the
left, the internal rectus is responsible for the deviation.
The test of movements in the different directions
should include a trial of the power of convergence by
DISORDERS OF OCULAR MOVEMENTS. 201
holding tho point looked at in the median plane and
bringing it steadily toward the nose until the patient can
no longer fix it with both eyes, but is compelled to allow
one of them to deviate. The nearest point that can be
fixed by both eyes at once is the near-point of con-
vergence.
Measuring the Amount of Squint. — Having
ascertained the presence of squint and its variety, the
next step is to measure its degree. The old plan of
measuring the deviation of the eye upon a rule held
before it, or laid along the edge of the lower lid has been
discarded for more accurate methods. One of these is
by the perimeter. The arc of the perimeter being
turned in the direction in which the eye deviates, the
squinting eye is placed at the center of the arc, just as
for the taking of its visual field. The fixing eye is then
turned toward some distant point, as some point across
the room, exactly in the line of the axis of the instru-
ment. The deviating eye would, if properly directed,
look toward the same point in the axis of the instrument.
The surgeon, noting where this eye is directed, reads from
the graduation of the arc the number of degrees of devia-
tion. To determine exactly the direction in which the
eye is turned, the surgeon's eye is moved along the arc
of the perimeter, with a candle-flame just in front of it,
and when the reflection of the flame from the patient's
cornea appears to be in the center of the pupil, the desired
direction of the deviating eye has been found. For the
candle-flame may be substituted an ophthalmoscopic mir-
ror reflecting a flame placed elsewhere.
To measure the degree of squint by the tangent of the
angle of deviation, the surgeon places his eye 1 meter
from the patient, in the dark room, and with the ophthal-
moscopic mirror throws the light on the patient's devi-
ating eye and watches its corneal reflex. The patient
fixes the surgeon's finger held 1 meter away and
moved in the direction opposite to that in which the eye
deviates, until the corneal reflection of the light appears
in front of the center of the pupil. When this is the
202 MEASURING SQUINT.
case, the patient's " deviating eye " is directed toward the
surgeon' s eye and" the ophthalmoscopic mirror, while his
" fixing eye " is directed toward the surgeon's finger. The
distance from the surgeon's eye to the finger is the tangent
to the angle of deviation. It may be measured on a tape-
measure or meter-stick, on which may be laid off a scale
of tangents. Approximately, each centimeter means an
angular deviation of 1 centrad, or the deviation of a 1
degree prism.
The tests as above described do not give exactly the
deviation of the visual line, but the deviation of a line
drawn through the center of curvature of the cornea and
the center of the pupil. Any notable departure of this
line from the visual line may be observed by covering
the patient's fixing eye and having him fix the sight-hole
in the ophthalmoscopic mirror with the eye that ordinarily
deviates, and noting the apparent position in the pupil of
the corneal reflex. If this be at the center of the pupil,
the two lines in question coincide ; if it be not at the
center of the pupil, its position is to be noted ; and the
reflex must be brought to this same position in measuring
the degree of squint.
The Diplopia Test. — If the patient can recognize
binocular diplopia, it gives the most accurate means of
measuring the degree of squint. It can be most favor-
ably tested by having the patient gaze at a small flame
4 meters distant in a dimly lighted room. If there is
difficulty in observing the false image, on account of the
extreme deviation or imperfect vision of the squinting eye,
the fixing eye may be covered with dark glass to dimin-
ish the vividness of its image ; or with the hand for a
little time, to allow the patient to notice the image belong-
ing to the deviating eye, before letting the other image
appear.
When the two images have been certainly recognized,
the covering of one eye causes its image to disappear,
indicating which image belongs to it. Or the better eye
may be covered with a colored glass to lessen the bright-
ness of its image and distinguish it by color.
DISORDERS OF OCULAR MOVEMENTS. 203
To measure the degree of. squint by the diplopia test,
prisms are placed before one or both eyes in such a way
as to bring the two images together. The strength of the
prisms required to do this is a measure of the degree of
the squint.
In general, the prism must be placed with the apex in
the direction in which the eye deviates. For instance, in
a case of convergent squint, the image belonging to the
right eye would be to the right, and that of the left eye
to the left. To bring them together, a prism must be
placed before the right eye with the apex to the left, or
before the left eye with the apex to the right. Other
methods of detecting and measuring squint are more
appropriately described under Heterophoria or Latent
Squint.
Varieties of Squint. — Strabismus, due to the par-
alysis or paresis of one or more of the muscles that turn
the eye in the orbit, occurs only when the weakened mus-
cle is called on to perform its function. There is actual
limitation of movement in a certain direction. This is
paralytic squint. In contrast to this are the cases in
which deviation depends upon a wrong co-ordination of
the movements of the two eyes, by which they habitually
converge too much or too little, so that the visual lines
intersect nearer or farther than the object fixed. Or the
two visual lines do not lie in the same plane, one going
higher than the other. These abnormal relations of the
visual lines are maintained, whatever the direction of the
pbject looked at. Squint of this kind is called comitant
or concomitant squint.
Paralytic squint may amount only to a weakness in a cer-
tain muscle or muscles, making necessary an increased
effort, or a compensatory action on the part of the other mus-
cles, to execute certain movements. This constitutes an in-
sufficiency of the muscle or muscles in question. Comitant
squint may amount only to a tendency of the visual lines
to deviate, a tendency habitually overcome by an effort, in
the interest of binocular vision. Such a tendency is ren-
dered evident when on, covering one eye, or otherwise
204 VARIETIES OF SQUINT.
preventing binocular vision, the visual lines deviate.
This tendency of the visual lines to deviate is called
heterophoria. Heterophoria has been used as synonym-
ous with insufficiency of the ocular muscles, and it is
convenient to consider both classes of cases together under
the heading Latent Squint. The term " insufficiency,"
however, will be here applied to the cases in which the
latent squint appears only when the attempt is made to
use a certain muscle or muscles, or to execute certain
movements like convergence ; and "heterophoria" will be
applied to those cases in which the tendency to deviation
appears during all sorts of ocular movements.
PARALYTIC SQUINT.
It is characteristic of a squint purely paralytic that,
when the eyes are in certain positions, no squint is present.
As the effort is made to turn them in a certain direction,
one eye commonly executes normal movements, while the
other does not move at all, or moves to less than the
normal extent. By the extent of the failure in normal
movement, it " deviates " from a normal position.
Causes of paralytic squint may affect either the mus-
cles themselves, the nerve-trunks, or the nerve-centers.
Those affecting the muscles themselves are chiefly wounds,
or the cicatrices caused by wounds, suppuration, or new
growths involving the muscle. Lesions of the nerve-
trunks are most frequent. They occur by swelling of
adjoining structures or hemorrhage, or are caused by
syphilis, rheumatism, renal and vascular disease, influenza,
and other acute diseases. Degenerations due to exposure,
alcoholism, or other toxic influences, may affect either the
nerve-trunks or the nuclei from which they arise.
Paralytic squint may be congenital. (See page 235.)
Varieties. — Each of the six ocular muscles may be
paralyzed alone, giving rise to its peculiar form of diplopia ;
or the palsies of two or more muscles may be combined
in various ways. The paralysis of the muscles supplied
by a certain nerve-trunk is a common association. Thus,
DISORDERS OF OCULAR MOVEMENTS. 205
we have paralysis of the oculomotor nerve, involving the
superior, internal, and inferior recti, and the inferior
oblique with the elevator of the lid, the ciliary muscle,
and the sphincter of the iris.
Recurrent oculomotor paralysis is a special form which
occurs in early life. The attack begins with extreme
headache, chiefly of one side of the head, nausea, and
vomiting, and edema and swelling of the orbital tissues
and lids of the affected side. After a few days the pain
and swelling subside, the muscles regain their power, and
the patient continues well for a period varying from a
few days to many months, then a similar attack occurs.
After a number of such attacks the ocular muscles fail to
regain their power, and there remains complete and perma-
nent oculomotor paralysis with recurrent attacks of pain.
The causes of this form of oculomotor paralysis are not
known. Paralysis of the fourth cranial nerve affects
only the superior oblique muscle ; and of the sixth nerve,
the external rectus.
Sometimes the paralysis affects only certain associated
movements. Thus, the vertical movements may be greatly
limited, although lateral movements are good ; converg-
ence may be lost, although either internal rectus acts
normally when the eyes are both turned to the right
or left ; or lateral movements may be wanting, although
the internal recti can still converge the eyes. Palsies of
this kind arise from lesions of the nerve-centers presiding
over the movements in question. They may be some-
times distinguished from peripheral palsies by the diffi-
culty or impossibility of fully fusing the double images
when these are brought together by prisms. Paralysis
of all the external muscles of the eye, without involve-
ment of the iris or ciliary muscle, is called ophthalmoplegia
externa.
Symptoms. — Paralysis of one or more ocular muscles
may arise suddenly, the patient awaking in the morning
to find the affected muscles absolutely powerless. More
commonly the symptoms gradually increase from day to
day for several days, or even for some weeks. In the
206 SYMPTOMS OF PARALYTIC SQUINT.
latter case the patient is conscious of gradually increasing
difficulty in using the eyes, which passes into noticeable
doubling of the images at some times, although at other
times there is no such difficulty. The patient may or
may not recognize that the doubling occurs only when he
looks in a certain direction ; and can be avoided by turn-
ing the he.ad instead of the eyes to look in that direction,
or by closing one eye.
Even after diplopia is established, the feelings of con-
fusion, strain, giddiness, and nausea continue. For in
one part of the field there remains normal single vision,
and between that part and the region of diplopia lies a
zone, where double vision is avoided only by increased
effort or the closing of one eye. Closure of the eye or
turning of the head to prevent diplopia becomes habitual.
The ocular symptoms may be accompanied by headache,
neuralgic pain from involvement of the sensory nerves,
or impairment of vision. Paralysis of more than one
muscle generally causes protrusion of the eyeball.
At first the deviation and diplopia may be confined to
half of the field of fixation or less. After a time the an-
tagonist of the paralyzed muscle, finding it no longer
meets with the accustomed resistance, undergoes what is
called a secondary contraction, so that the eye, instead of
remaining properly directed when at rest, is permanently
turned from the paralyzed muscle. This is best illus-
trated in the turning out of the eye in paralysis of the
oculomotor nerve, which involves all the adductors of the
eyeball. Secondary contraction may not occur with con-
genital palsies.
Secondary deviation occurs in the sound eye, when it is
covered and the affected eye attempts to fix. The weak-
ened muscles of the affected eye are able to fix it only by
an effort in excess of the normal ; and this excessive
effort, extending to the related muscles of the sound eye,
causes in it an excessive deviation. The secondary devia-
tion, being greater than the primary, is sometimes an
important diagnostic sign of paralytic squint.
Diagnosis. ^-The presence of paralytic squint is
DISORDERS OF OCULAR MOVEMENTS. 207
proved by limitation of the movements of an eye, or by
diplopia confined to one part of the field of vision, and
increasing the farther the eyes are turned in that direc-
tion. In determining the variety of the squint, and the
particular muscle affected, the first point is to ascertain
which eye does not move normally. In severe cases this is
readily ascertained by watching the motions «f the eyes,
as they turn to follow an object moved in different direc-
tions. If the deviation is slight, this will be more
difficult. If vision is equally acute in both eyes, the
patient will incline to use the unaffected eye, fixing
with it and allowing the other to deviate. If, however,
vision is decidedly better in the affected eye, it may
be used for fixation, and the sound one will appear to
deviate.
Which eye fixes is determined by letting the patient
look at some point in the field of deviation, and then
intermittently covering one eye. No movement occurs
if the deviating eye is covered ; but when the fixing eye
is covered, the deviating eye moves to fix. Often the
patient's impression is correct as to which is the false
image and which the true one, but not always.
The second point in the diagnosis is to ascertain which
image belongs to the right eye and which to the left. This
may be done by covering one eye and asking which image
disappears ; but sometimes the patient is mistaken in his
answer, because if the fixing eye is covered, the deviating
eye may move so quickly to fix the object looked at, that
the corresponding change of its image is unnoticed. The
false image having moved to take the place of the true
image, it is supposed that the false image has disappeared
while the true one has remained. By placing before one
eye a piece of red or blue glass, the patient, noticing
which image is colored red or blue, can always decide
which image belongs to that eye.
The third point is to find what movements of the eyes
cause the widest deviation of the affected eye, the widest
separation of the true and false images. This is done by
moving the object looked at into various parts of the field
208 DIAGNOSIS Of PARALYTIC SQUINT.
of vision, or having the patient turn his head in various
ways while looking at a fixed object like a lamp-flame.
The fourth point is to ascertain whether the double
images remain parallel or incline toward each other at the
top or bottom in various parts of the field ; and if they
are inclined, what the inclination is, and in what part of
the field it is the greatest. This is done by having a long
object, such as a white ophthalmoscope handle with a
dark background. This object should be placed vertically,
and the patient asked if the false image remains vertical,
parallel to the true image in all parts of the field ; or, if
inclined, whether they are closer together at the top or
bottom. The one image remaining vertical may show
which eye it is that deviates.
Finally, the patient must observe whether the two
images are on the same level, or whether one of them is
higher than the other ; and which is higher, and in what
part of the field the difference of level is greatest.
The recti muscles attached in front of the center of
rotation turn the cornea towards their insertions, as the
superior up. The obliques attached behind the center of
rotation turn the cornea from them, as the superior down-
ward. The eye lags in the direction the paralyzed muscle
should turn it, and the resulting false image is projected
too far in that direction. The greatest separation of the
images occurs with the attempt to turn the eyes in the
direction the paralyzed muscle should carry them.
Paralysis of the external rectus limits movement of
the eye toward the affected side. If the right eye be in-
volved, it cannot be turned to the right ; if the left eye,
it cannot be turned to the left. It causes a convergent
squint which increases as the eyes are turned toward the
affected side. The diplopia is homonymous, the images
separating as the eyes turn toward the affected side. The
images are the same height and parallel, or slightly tilted
when looking down or up.
Paralysis of the superior rectus limits movement up-
ward, the deviation and distance between the images
increasing in that direction. The false image is the
DISORDERS OF OCULAR MOVEMENTS. 209
higher, and toward the sound side (crossed diplopia) the
images are nearly parallel when the eyes are turned
toward the affected side ; but the false image is tilted, its
top from the true image, when the eyes are converged or
turned toward the sound side.
Paralysis of the Internal Rectus. — The eye tends to
deviate outward (divergent squint), the deviation increas-
ing as the eyes are converged or turned toward the sound
side. The diplopia is crossed, the images separating as
the eyes are turned toward the sound side. The images
are about on a level and parallel, unless the eyes are
turned strongly up or down, when some tilting occurs.
Paralysis of the inferior rectus limits the movement
of the affected eye downward, and the distance between
the images increases on looking down. The false image
is the lower, and is toward the sound side (crossed diplo-
pia). The images are parallel when the affected eye is
turned somewhat out (looks toward the affected side) ; but
the false image is tilted, top toward the true image, when
the affected eye is turned in (looks toward the sound side).
Paralysis of the superior oblique limits movement
downward and outward, and the images separate most
widely in this direction. The false image is toward the
affected side (homonymous diplopia), and is most tilted
when the eyes are turned toward the affected side. When
the eyes are turned toward the sound side, the images are
about parallel, and the false image decidedly the lower.
Inferior oblique paralysis causes limitation of the
movements upward and outward, and the images separate
most widely in those directions. The false image is
toward the affected side (homonymous diplopia) and
higher. It is most tilted on looking toward the affected
side, the top from the true image, and is about parallel
and most elevated on looking toward the sound side.
In Figs. 77 to 82, inclusive, the black bars mark the
part of the field in which there is single vision ; the bars
with the lines running up to the right indicate the image
belonging to the right eye ; and those with lines running
up and to the left, the image belonging to the left eye.
14
210
DIAGNOSIS OF PARALYTIC SQUINT.
The bars which are darkly shaded represent the true
image, and those which are lightly shaded the false image.
B 1
1
1
1
1
I I
II
1
1
1 I
I 9
1
1
1
1
II
Left
FIG.
Right.
77.— Paralysis of external rectus.
I
\
1
/
1
1
1
1
I
1
Left. Right.
FIG. 78.— Paralysis of superior rectus.
I I I
I I I
Left. Right.
FIG. 79. — Paralysis of superior oblique.
Differential Diagnosis. — Homonymous diplopia
— convergent squint — occurs in paralyses of the ocular
muscles, which are thus differentiated :
DISORDERS OF OCULAR MOVEMENTS.
211
I I
I I
I I
I
I I
Left. Right.
FIG. 80.— Paralysis of internal rectus.
I I I
Left. Right.
FIG. 81.— Paralysis of inferior oblique.
I I I
I I I
I I I
Left. Right.
FIG. 82.— Paralysis of inferior rectus.
External Rectus. — Images the same height and parallel.
They separate most widely on looking toward the affected
side.
Superior Oblique. — Images separate on looking down,
the false image tilted on looking toward the affected side,
displaced downward on looking toward the sound side.
Inferior Oblique. — Images separate on looking up, the
212 DIAGNOSIS OF PARALYTIC SQUINT.
false image tilted on looking toward the affected side,
displaced upward on looking toward the sound side.
Crossed diplopia — divergent squint — attends three
palsies :
Internal Rectus. — Images of the same height and par-
allel. "iThey separate most on looking toward the sound
side.
Superior Rectus. — Images separate on looking up, par-
allel toward the affected side ; tilted with the tops apart
on looking toward the sound side, the false image higher.
Inferior Rectus. — Images separate most on looking
down, are parallel when looking toward the affected side ;
and tilted, tops together, in looking toward the sound side,
false image lower.
Treatment. — In the early stages this will depend
upon the cause. • A palsy from traumatism will require
rest. Jf the history points toward syphilis, potassium
iodid or the mixed iodids, in doses rapidly ascending to
the maximum, will be indicated. These should be con-
tinued for at least two months, unless recovery is complete
before that. Even if there be no history of syphilis, but
the etiology is obscure, the same treatment is admissible.
If there is rheumatism, or a history of "cold," sodium
salicylate may be given in full doses for two or three days,
or sometimes longer ; then the iodids may be resorted to,
and continued for several weeks. At the very outset,
cases of this kind may be favorably influenced by a hot
bath, or a pilocarpin sweat.
When the paralysis is due to diphtheria, or chronic
poisoning, or arises in connection with degenerative dis-
ease of the central nervous system, the treatment should
from the start include general tonics and strychnin in
ascending doses, until decided improvement occurs, or the
maximum physiological dose has been reached and kept
up for several weeks-. In cases of this kind, change of
residence, occupation, or manner of living may be im-
portant. These measures may be beneficial in the later
stages of paralysis from all causes.
When the paralysis has continued two or three weeks,
DISORDERS OF OCULAR MOVEMENTS. 213
electricity may be tried, the positive pole being placed as
closely as possible over the affected muscle, and the nega-
tive behind the ear or on the back of the neck. When
the paralysis has continued many weeks, and seems
stationary, muscle-stretching may be resorted to. Under
cocain the insertion of the tendon of the muscle is seized
with fixation-forceps, and the eye slowly and forcibly
rotated to and fro so as alternately to stretch and relax
the paralyzed muscle. The rotation both ways is repeated
ten or twelve times a minute for two or three minutes, at
each sitting ; and the sittings repeated every two or three
days. The manipulation must not be so violent as to
cause serious subsequent soreness, yet the paralyzed mus-
cle and its antagonist should be decidedly stretched.
When the case has become chronic, and the extent of
the squint fixed (or in cases of moderate paresis from an
earlier period), prisms may afford relief. The base of the
prism before the affected eye should be turned toward the
weakened muscle, and the prism before the sound eye
correspondingly placed. Prisms thus placed render pos-
sible binocular single vision, while the eye deviates
toward the apex. Prisms thus worn must be watched,
and the strength varied according to the changes in the
deviation. Prisms may also be used turned the opposite
way (with the apex toward the weakened muscle), to
compel its more powerful exertion, and thus to develop
its strength. For this purpose they are to be used only a
few minutes at a time, one or more times a day.
A better method of giving the weakened muscle gym-
nastic exercise and training is to have the patient fix
both eyes upon a small object held in the portion of the
field of vision where there is no diplopia, and then slowly
moving the object over into the field of diplopia, keep it
single as long as possible. As soon as diplopia occurs in
spite of a strong effort, the effort is to be suspended, and
the eyes are to be allowed to rest for a minute or so.
Then the exercise may be repeated. Each effort should
occupy ten or fifteen seconds, and it may be repeated
several times at a sitting, with several sittings a day. In
214 TREATMENT OF OCULAR PALSIES.
the earlier trials care should be taken not to overstrain
the weakened muscle.
To escape the vertigo and annoying diplopia, while
these continue, the deviating eye may he covered by a
ground, ylass, or by a piece of tissue paper, pasted on the
back of the patient's ordinary spectacles. Sometimes it
is better to shut off in this way only the part of the field
of vision in which diplopia or confusion of sight occurs,
leaving the eye free for binocular vision in the other parts
of the field.
When paralytic squint has become partly comitant,
the operative treatment of the latter may be applicable ;
and even if the squint be still chiefly paralytic, the
patient can in a few cases be given decided help by an
advancement of the aifected muscle, or a tenotomy of its
antagonist, or both. This will be the case when by
operation it will be possible to remove the field of diplopia
from directly in front, or from the direction in which the
patient wishes to use his eyes habitually, to some other
part of the field of vision. Sometimes an operation may
be done for cosmetic reasons.
Prognosis. — Paralytic squint, seen early and appro-
Jriately treated, is cured in a large proportion of cases.
f due to syphilis or rheumatism, at least partial recovery
may be expected. Diphtheritic paralysis of the ocular
muscles does not show the same strong tendency to com-
plete recovery shown by other diphtheritic palsies,
although its prognosis is favorable. Nuclear palsies,
coming early in degenerative disease of the central nerv-
ous system, are especially variable in the degree of dis-
ability they cause ; they sometimes go on to practically
complete recovery, although the general disease continues
to advance. Partial recovery from paralysis of the
external rectus, or superior oblique, leaves the patient
without noticeable deformity, and often still able to use
the eyes freely without diplopia or serious inconvenience.
But permanent partial paralysis of the oculomotor nerve
is mostly accompanied with marked divergence of the
eyeball, and limitation of its movements, drooping of the
DISORDERS OF OCULAR MOVEMENTS, 215
lid, diplopia on raising the lid, and inability to use the
affected eye. In recurrent oculomotor paralysis the
recoveries from successive attacks become more and more
incomplete, until complete disability of the affected mus-
cles becomes permanent. The diplopia of paralytic squint
continues, and gives annoyance so long as the deviation
lasts.
COMITANT SQUINT.
The same deviation occurring in all parts of the visual
field, is the characteristic of comitant squint. It may
not be the same at different times, it may part of the time
be entirely absent, but when present it is not confined to,
or greater in, one part of the visual field than another.
Since both eyes do not turn toward the same point, it
is evident that only one can " fix," and the other one
must " deviate." Habitually the patient inclines to use
his better eye, if there is even a slight difference between
them, and the eye with the poorer vision is allowed to
deviate. But it must not be thought on that account that
the squint belongs in any peculiar way to that eye, rather
than to the other. True comitant squint is a false co-
ordination of the two eyes ; it is a disorder of their rela-
tion. Either eye alone is absolutely normal, one just as
normal in its movements as the other; you must have
two eyes to have a squint.
Causes. — Typical paralytic and comitant squint have
thus far been considered, but many cases occur of
mixed type. When secondary contraction of its antagon-
ist has occurred, recovery of power in a paralyzed muscle
gives rise to a comitant squint. With full recovery
of power, secondary contraction may be overcome and the
squint disappear; but in the presence of other conditions
that tend to cause squint, in spite of the full recovery of
the paralyzed muscle or muscles, the squint continues.
This is probably the mode of origin of a considerable
proportion of cases of comitant squint.
Binocular vision, and the accurate co-ordination of the
movements of the two eyes are functions almost or quite
216 CAUSES OF COMITANT SQUINT.
peculiar to man. They are mutually dependent. While
binocular vision is impossible without the accurate co-
ordination of the movement of the two eyes, such accurate
co-ordination is usually impossible except under the
guidance of binocular vision. The two develop together,
usually during the first weeks or months after birth, but
sometimes they are not perfected until the child is several
years old. During the period of their incomplete develop-
ment they are most easily prevented or overthrown.
Hence, most cases of comitant squint arise in early child-
hood.
Removal of the guidance of binocular vision is likely
to impair the binocular co-ordination of movement at any
age. Hence, complete blindness of either eye is likely to
cause squint. Great impairment of vision from corneal
injury or diseas£, which causes distortion or blurring of
the retinal images by the admission of diffuse light, is
likely to cause squint. On the other hand, very imperfect
vision with normal retinal images may furnish the neces-
sary guidance to binocular adjustment. Congenital defects
of the retina at the fixation-point, or of the optic tracts or
centers causing central scotoma, are likely to cause squint;
but injury of these parts by disease, after binocular move-
ments are well established, will not cause it.
It is probable that in a few cases anomalies in the
attachments or strength of the ocular muscles tend to
cause squint. But the enormous adaptability these muscles
show when the eyeball is displaced by tumor, or after
their mutilation by ill-advised operations for heterophoria,
makes it improbable that such mechanical influences as
are exerted by a certain general shape of orbit, or width
between the orbits, play any important part in causing
squint. The very intimate association of errors of refrac-
tion with certain kinds of squint is dealt with in connec-
tion with these special varieties.
Varieties. — Constant squint, as its name implies, is
always present, but it may from time to time vary greatly
in degree. If the squint be part of the time entirely
absent, it is called intermittent or periodic squint) but it
DISORDERS OF OCULAR MOVEMENTS. 217
presents no strictly regular periodicity. Accommodative is
a form of intermittent squint that appears only when the
accommodation is strongly exerted. When one eye habit-
ually fixes and the other habitually deviates, the squint
is called monolateral or monocular. If both eyes see
equally well and with the same effort, sometimes one will
fix, and sometimes the other. This is called alternating
squint. Even when there is a slight difference between
the eyes, the squint may be at first alternating. It may
also alternate when the refraction of one eye adapts it to
distant vision, while that of the other fits it only for near-
seeing.
Squint occurring as a form or part of a convulsive
seizure may be called convulsive squint. Closely allied to
it is squint occurring as a manifestation of hysteria,
hysterical squint (see Spastic Squint).
Convergent squint is the commonest, variety. The
visual axes are at all times converged. On looking at
distant objects they converge least ; on looking at near
objects they converge more strongly. At. all times the
convergence is excessive, the visual lines intersecting
nearer to the eye than the point fixed. In the popular
mind this variety has long been associated with the efforts
of young children to look at objects held too close to the
eyes. It is usually established before the age of six years.
Donders pointed out that it had a connection with hyper-
opia. Hyperopia requires excessive exertion of accom-
modation. Accommodation is closely associated with
convergence, therefore hyperopia tends to produce ex-
cessive convergence. But every pair of convex or con-
cave lenses worn affects the amount of accommodation
exerted, yet usually the permanent influence they exert
on the convergence of the eyes is insignificant, so that
the necessary influence of hyperopia in causing conver-
gent squint is for many cases slight. Then, since 70 per
cent, of all persons are hyperopic, mere coincidence would
account for the hyperopia in that proportion of the cases
of convergent squint.
But there is a frequency of association between con-
218 CONVERGENT SQUINT.
vergent squint and hyperopia of high degree, 3. to 6. P.,
that coincidence does not explain. These cases of squint
are usually intermittent, or if constant are quite variable
in degree. The squint increases greatly when the eyes
are used for accurate seeing, especially for near vision.
Other causes of squint, as imperfect vision, or a previous
ocular paralysis, are mostly absent from these cases, and
correction of the hyperopia cures the squint. Such cases of
squint seem clearly due to an overflow of nervous impulse,
which affects the convergence from the excessive effort
of accommodation.
Divergent squint is a condition of relatively deficient
convergence. On looking at a distant object the visual
lines may diverge, on looking at a near object they may
become parallel or even convergent, but they never con-
verge enough to meet at the object looked at. Aside
from blindness and previous oculomotor paralysis, diver-
gent squint usually arises in connection with myopia; and
since myopia is usually acquired, it comes on later in life
than convergent squint.
The myopic eye> having to accommodate but relatively
little, loses whatever stimulus accommodation may give
to aid convergence. Far more important factors, how-
ever, in the causation of divergent squint are found in
the excessive amount of convergence required by myopic
eyes, and the excessive difficulties of convergence on
account of the elongation of the eyeball already re-
ferred to (p. 159). These conditions also constitute the
most serious obstacles to the correction of this form of
squint.
Divergent squint usually begins by simply allowing
the worse eye to diverge relatively, when very near
objects are looked at, while at other times its direction is
normal. At first the squint is intermittent, merely a
failure to converge strongly, when strong convergence is
required to fix the object. But when once this habit is
established, the deviation is liable to become more fre-
quent and greater, until the squint occurs at all distances,
and becomes constant. Alternating divergent squint is
DISORDERS OF OCULAR MOVEMENTS. 219
rare, since in high myopia one eye usually has decidedly
better vision than the other.
Vertical squint is the deviation of one eye upward or
downward, so that its visual line no longer lies in the
visual plane — the plane passed through the centers of
rotation of the two eyes, and the point on which the gaze
is fixed. It occurs separately, either from traumatism or
as a sequel to a paralytic squint, but it occurs far more
frequently in connection with convergent or divergent
squint. Indeed, marked lateral deviation is usually
accompanied by some departure of the visual line of the
deviating eye from the visual plane. Such deviation is
more frequently upward than downward.
Symptoms. — Comitant squint generally first attracts
attention by the appearance of the deviating eye. The
deviation is usually greater at some times than others.
In some cases it is most noticeable when the patient is
tired, in others when excited or angry. The patient may
think it intermittent, when in reality it is only variable.
The patient is not likely to underrate the importance of a
visible squint ; but parents and friends, who have become
accustomed to the deformity, often fail to realize the
suffering and disadvantage of such deformity to a young
person.
Diplopia is rarely complained of, and in some cases it
cannot be produced. It is most likely to cause annoy-
ance in squint developed in adult life. Comitant squint
is not likely to cause symptoms of eye-strain, except
in those cases in which the squint is intermittent, and
gives rise to such serious diplopia that the patient by
a special effort prevents the squint or renders it latent a
part of the time, to avoid the diplopia. Of the impaired
judgment as to distances, lessened field of vision, or other
disabilities caused by the lack of binocular vision, the
patient is not usually conscious. The connection of am-
blyopia with squint has been sufficiently discussed
(p. 198).
Diagnosis. — To determine whether squint is real or
apparent, the test of alternately covering the eyes (see p.
220 .DIAGNOSIS OF COMITANT SQUINT.
199) is to be used. This will also, by the extent of the
secondary deviation, indicate whether the squint is par-
alytic, or partly of that character. If the squint is
monolateral, the fixing eye will immediately return to
fixation as soon as it is uncovered, and the deviation
return to the other eye. If the squint be alternating,
either eye, when made to fix, will continue to fix when
both eyes have been uncovered. The amount of squint
should be measured (see p. 201) repeatedly, at different
times and under different circumstances.
If the deviating eye has useful vision, a careful attempt
should be made to secure binocular diplopia. The fixing
eye being covered, the deviating eye is made to fix a
lamp-flame in the darkened room. Then the fixing eye
is allowed to look through colored glass, so dark as to
lower its acutene'ss of vision even below that of the de-
viating eye. Repeated trials may be required before the
false image is recognized, but practice renders the recog-
nition easier and more certain. Sometimes a strong
prism, so placed as to bring the false image nearer to
the macula, aids greatly in its recognition. The fusion
tubes of Priestley Smith furnish a useful means of recog-
nizing diplopia, and training the patient to overcome it.
They consist of two short cylinders, each with a convex
lens in one end, and a cap with a hole in it at the other.
The tubes are freely movable with reference to each other.
If both holes are seen at once, we have evidence of
diplopia, and by turning the tubes so as to fuse the images
of the two openings, we can ascertain the directions taken
by the visual axes.
When binocular diplopia has been secured, an effort
should be made to bring the true and false images together
with prisms. These are to be turned with their edges in
the direction in which the eye deviates. If the images
when brought together with prisms can be fused, giving
binocular vision, complete cure by operation may be pos-
sible. If, however, the images when brought together
refuse to become one, falling short of each other with one
prism, and then jumping past each other when the strength
DISORDERS OF OCULAR MOVEMENTS. 221
of the prism is slightly increased, and if this persists at
repeated trials, cure cannot be expected, and accurate cor-
rection of the deviation may cause annoying diplopia. The
complete diagnosis of any case of squint must include
the careful measurement of the refraction and accommo-
dation of the eyes in young children by skiascopy.
Treatment. — This should begin as soon as the squint
is recognized, and include the constant wearing of accu-
rate correcting lenses, systematic use of the worse eye,
fusion training, and in some cases operation.
Use of the Deviating1 Bye. — If cycloplegia confined
to the better eye be not sufficient to induce the patient to
use the other, we keep the former excluded from vision by
some kind of bandage, or by cotton placed behind its
correcting lens. This exclusion should at first continue
but a few minutes, but be repeated several times a day.
Later, the periods may be lengthened until this eye is used
continuously ; or the patient fixes with it, when his better
eye, under a cycloplegic, is uncovered. If this cannot be
attained, hope of binocular vision must be given up, and
cosmetic improvement alone expected.
Fusion Training. — When the eyes have become accus-
tomed to the glasses, and the patient has learned to fix
with the previously deviating eye, exercises to develop
the fusion faculty should be undertaken. For young
children the fusion tubes described above, and the Amblyo-
scope of Worth, are most important. The latter is a
reflecting stereoscope in which the images to be fused are
placed at the distal ends of two angled-tubes into which
the patient looks, and are seen by light passing through
them. The illumination is adjustable, either by especial
apparatus, or by turning one tube toward the window or
lamp, and the other toward comparative shadow. The
stronger illumination is given the image presented to the
poorer or previously deviating eye. When the light is
properly adjusted the two images become equally notice-
able. The angle between the tubes is then varied until
the two images are superimposed.
The monoscope, suggested by the writer, consists of two
222 TREATMENT OF COMITANT SQUINT.
mirrors placed before one eye, with smoked glasses to
reduce the illumination and equalize the images. One
mirror is movable so that it can be placed parallel to
the other, or for squint at such angle as to throw on the
fovea of the one eye an image of the object fixed by the
other eye. It requires no special pictures, but can be
used in looking at ordinary objects. Fusion training is
chiefly valuable during early childhood. If the deviation
be not too great, and some progress has been made in binoc-
ular fusion, for older persons the ordinary hand stereo-
scope, with special pictures and diagrams, is of value.
The first step in fusion training is to bring about con-
sciousness of the images received through both eyes. The
next step is to secure fusion, a single perception of the
parts common tq^ both images. A third step is to main-
tain this fusion when the angle between the tubes is
varied. With the power to do this comes ability to
recognize depth or relief in the binocular image. All
exercises for fusion should be given in very short sittings.
They are useful only so long as they command the close
attention and active effort of the patient.
For convergent squint the wearing of correcting lenses
may begin at the age of two years. While the eyes are
under a cycloplegic the child will adopt the glasses at
once. Fusion training may begin equally early. Where
it is impossible for a time to adopt other treatment, both
eyes, or in monolateral squint, the better eye, may be kept
continuously under the influence of atropine. Careful
attention should be given to the patient's general health,
especially where convergent squint has seemed to follow
acute disease in childhood, or divergent squint is asso-
ciated with bad hygienic conditions.
Operations. — When squint persists after trial of the
above measures, operative treatment must be considered.
The habit of excessive convergence may be the chief
obstacle to development of the fusion faculty. If a young
child with fixed convergent squint is found by the fusion
tubes to possess capacity for binocular vision, and when a
few weeks wearing of correcting lenses and other treat-
DISORDERS OF OCULAR MOVEMENTS. 223
ment leaves the squint constant and but little diminished,
an operation should be done to give the non-operative
treatment a better chance for proving effective. Opera-
tions so done to facilitate fusion training should reduce the
degree of deviation rather than aim completely to correct
it, and should be followed immediately by fusion training.
In older patients, where the period for the development
of the fusion faculty is quite passed, if the ametropia be
of moderate or high degree, it is best to continue the
wearing of the correcting lenses at least six months before
attempting to correct the deviation by operation. If the
deviation be moderate it is well to defer operation until
after puberty. In adults who have constant squint of
long standing, without ametropia that would otherwise
require correction, operation for its cosmetic effect may
be undertaken as soon as the case has been properly studied.
Intermittent squint should not be treated by operation ;
unless when the squint appears to be absent it is found to
be merely latent or suppressed.
The operations for squint are tenotomy of a muscle
which seems to turn the eye too strongly in its direction ;
tenotomy extended to the muscles that assist in producing
or maintaining extreme rotations of the eye ; advance-
ment of the muscle which does not exert sufficient influ-
ence on the movements of the eyeball ; lateral displace-
ment of a tendon insertion, to modify the character of its
action, or some combination of two or more of these
operations.
Very different effects are yielded by the same opera-
tion in different cases of squint, but ordinarily we expect
a simple tenotomy to correct 15 or 20 centrads of devia-
tion inward, or less outward. A small deviation may be
corrected by advancement alone ; a greater deviation
requires extended tenotomy, or tenotomy with advance-
ment of the opposing muscle. Advancement is less likely
to be followed by excessive effect than tenotomy ; and
where the immediate effect is excessive, a looser stitch
may be placed and the original stitch removed. Extended
tenotomy is applicable only to rather high degrees of con-
vergent strabismus. It is best to plan the operation so that
224 EDUCATIVE TREATMENT.
it will slightly (3 to 5 degrees) under-correct a convergent
squint ; or over-correct a divergent squint.
After a squint operation, if binocular vision is to be
hoped for, fusion training should be promptly tried, and
the operated eye left open so that it can participate in
vision while still unable to deviate as it has been accus-
tomed to do. In older patients, after operation, in addition
to the methods of fusion training previously mentioned,
and especially the stereoscope, controlled reading may be
resorted to. A reading bar or ruler is held in front of
the page so as to hide part of each line from either eye ;
hiding one part from the right, and a different part from
the left. The patient on attempting to read finds it neces-
sary to use both eyes ; and hence, easier if he keeps both
eyes directed toward a single point — binocular fixation.
Prisms and decentered lenses, which have a prismatic
effect, are of little value for divergent or convergent stra-
bismus, because they cannot be habitually worn strong
enough to match the deviation of the eyes. For vertical
strabismus which is often less in amount, they may be
more serviceable. They do not " correct " the strabis-
mus, but " allow " it, enabling the patient to gain binoc-
ular vision while still squinting. They can be used some-
times with advantage to assist the eyes in their early
efforts at fusion. Or, they may be useful temporarily in
supplementing or correcting the effects of an operation.
Their chief value, however, is in the treatment of latent
squint, or heterophoria, in which connection their use is
explained in detail.
Prognosis. — Squint noticed in early childhood some-
times disappears without treatment. But this is no reason
to defer treatment. The large majority of squints do not
so disappear ; and waiting for spontaneous recovery, we
lose the only time when, complete recovery can be brought
about by treatment. Of cases treated during the first
month, more than half are capable of complete cure with-
out operation. When the squint has lasted a year, or in
convergent squint, when the patient has passed the age
of four years, complete cure is less likely; and after six
years it is rarely possible. The cosmetic correction of
DISORDERS OF OCULAR MOVEMENTS. 225
squint, so that the deviation may be reduced to less than 1 0
centrads and be very little noticed, can generally be
effected by a proper operation. But the result will only
be permanently satisfactory in properly chosen cases of
fixed squint. It should be remembered that even among
adult patients, especially those suffering from divergent
squint, are some, who having developed binocular vision
before the squint commenced, are capable of recovering it.
LATENT SQUINT.
When a patient with habitual binocular vision, upon hav-
ing one eye covered, allows it to deviate, he is said to have
a latent squint. The assumption is that the position taken
when binocular vision is prevented is a position of rest or
of lessened effort ; that binocular vision is only maintained
by a special exertion, which the perfectly balanced eyes
do not have to make. This is clearly the case in paralytic
squint in a zone between the portion of the field where
movements are strictly normal, and the portion where
diplopia occurs in spite of any effort ; or in a case of
insufficiency of convergence, before the effort becomes
too great to be sustained, and relative divergence occurs.
Varieties. — Formerly all cases of latent squint were
called " insufficiencies of the ocular muscles." At that
time only those here classed as insufficiencies were gene-
rally recognized. Heterophoria has recently been used
as a synonymous term ; but its proposer, Dr. Stevens,
considered chiefly the conditions here classed as heter-
ophoria, largely ignoring the true insufficiencies, except in
so far as provided for in the awkward classification
" heterophoria in accommodation." An insufficiency of
an ocular muscle is a latent paralytic squint. Hetero-
phoria is latent concomitant squint. The distinction
between the two classes of cases should be recognized in
diagnosis and treatment. Muscular Imbalance is another
term used to indicate the conditions under discussion.
Insufficiency may involve either of the six extra-ocular
muscles, giving rise to the same deviations, as do paraly-
15
226 UETEtlOPBOttlA AND INSUFFICIENCIES.
ses of these muscles ; these deviations do not occur
until binocular vision is prevented as in the tests for
latent squint. For example, insufficiency of the right
external rectus will cause latent squint only when the
eyes are turned to the right, which will increase the
farther they are turned in that direction. This squint
will be convergent ; the diplopia it causes, homonymous.
If symptoms arise from such a latent squint, they will be
connected with the turning of the eyes to the right. Such
a condition might be termed a paresis of the external
rectus muscle ; but for practical reasons, the term paresis
should be reserved for cases of incomplete paralysis in
which the squint is not wholly latent, diplopia occurring in
a portion of the field. The other insufficiencies recognized
in practice are Insufficiencies of certain muscle-groups,
as of the muscles supplied by the oculomotor nerve ; and
insufficiencies of certain movements, as insufficiency of
vertical movements or insufficiency of convergence.
The last variety is of most practical importance. A
tendency to relative divergence of 4 or 5 centrads at the
ordinary distance for near work, about one-third of a
meter, must be regarded as normal. Closer than this the
tendency to relative divergence increases until for each
pair of eyes a certain point, the near-point of convergence,
is reached. But quite frequently the relative divergence
at the working distance is found greater than normal.
Especially in presbyopes and myopes this is the case.
A majority of the latter show marked latent divergence.
Heterophoria , a tending of the two visual lines toward
different points, is a departure from Drthophoria, the
tending of the visual lines toward the same point. Its
varieties are : Esophoria, latent convergent squint, a tend-
ing of the visual lines to intersect nearer than the point
fixed : Exophoria, latent divergent squint, a tending of
the visual lines either to diverge or to meet beyond the
point fixed ; and Hyperphoria, latent vertical squint, a
tending of one visual line above the other. The term
Qataphoria, the tending of one visual line below the other
is unnecessary, since all cases of latent vertical squint are
DISORDERS OF OCULAR MOVEMENTS. 227
either right hyperphoria, tending of the right visual line
above the left, or left hyperphoria, a tending of the left
visual line above the right. Mixed deviations are also
recognized as hyper-esophoria, where one eye tends to
deviate upward and inward.
Causes. — The causes of latent squint include some of
the causes of actual squint, opposed by a well-developed
power of binocular co-ordination and fusion. Take away
the impulse to binocular fusion, and the squint ceases to
be latent.
Symptoms. — Headache and eye-ache are the most
constant symptoms of latent squint, while vertigo or a
sense of strain, or a feeling of mental confusion may be
present in severe cases. The headache has been regarded
as more likely to be occipital than the headache due to
anomalies of refraction ; but there is 110 very marked
difference in this respect. All the manifestations of
asthenopia or eye-strain may occur in connection with
latent squint; but congestion and inflammatory changes
either in the eye or related parts are less common. The
connection of such grave nervous disorders as epilepsy
and chorea with heterophoria is very doubtful, except as
heterophoria arises from the disturbance of the ocular
muscles by these diseases. In a few cases, actual squint
and diplopia may be discovered at times or in parts of
the visual field, in patients in whom such deviation of
the eyes had never been noticed.
Diagnosis. — The presence of latent squint is revealed
only by special tests. On covering one eye, that eye devi-
ates ; on uncovering, both eyes fix normally. The move-
ment of deviation is often quite gradual, occupying some
little time after the eye has been covered, and on this
account it is difficult to perceive. But the movement of
readjustment, or " recovery," is instantaneous, and there-
fore more noticeable. A recovery of 2 or 3 degrees is
readily observed.
But entire exclusion of one eye from vision is not
necessary to reveal latent squint. Placing before one eye
a piece of dark blue or purple glass will so change the
228 DIAGNOSIS OF LATENT SQUINT.
color of an ordinary lamp-flame as to overcome the ten-
dency to binocular fusion. The eye will deviate, and a
false image having the color given by the glass will be
seen. The direction of the false image and the distance
of its separation from the true image will indicate the
kind and degree of the squint.
The most valuable test for latent squint is the Maddox
rod. A piece of glass rod placed before one eye, acting
as a very strong cylinder, produces such a distortion of
the images formed by light passing through it, that all
tendency to fuse them with the images of the other eye
is overcome. On looking at a point of light, as a small
flame at a distance of 4 to 6 meters, this appears as a
long streak, perpendicular to the direction of the rod.
If the balance of .the ocular muscles is perfect, this streak
appears to pass directly through the point of light as seen
by the other eye, as in Fig. 83, A. But in latent squint the
FIG. 83.— Positions of streak of light seen with the Maddox rod test : A,
orthophoria ; R, hyperphoria ; C, exophoria or esophoria, according as the rod
is held before the right or the left eye.
streak appears displaced in the direction opposite that of
the deviation. Thus if there be a right hyperopia, the
rod placed before the right eye will show the streak below
the point of right, as in Fig. 83, B. To test this vertical
balance the rod is placed vertically, causing a horizontal
streak. To test the lateral balance it is placed horizon-
tally, causing a vertical streak, which in esophoria or
exophoria appears to pass to the right or left of the light,
as in Fig. 83, C. To test the balance at the near-work-
ing distance, a point of light is not readily used and
a white spot, 1.5 to 2 mm. square, on a black card,
DISORDERS OF OCULAR MOVEMENTS. 229
is substituted. The ordinary Maddox rod gives with
such a spot so feeble a streak that it is better to employ a
piece cut, from the side of a large rod, or a cylindrical
lens of 20. or 30. D. refracting power.
The Graefe Test consists in placing with its base
directly up before one eye, a prism strong enough (8
or 10 degrees) not to be "overcome" by the turning
of one visual axis lower than the other : this causes
vortical diplopia. On looking at a black dot on a white
card, two images of the dot are seen. If the lateral bal-
ance of the muscles be perfect, one image is directly below
the other ; if there be latent lateral squint, the lower
image will be displaced laterally. Graefe proposed this
test to detect insufficiency of convergence. It is less
useful for testing the vertical balance.
The Maddox double prism consists of two prisms
ground on one piece of glass, base to base. It is placed
before one eye so that the line joining the two prisms
passes horizontally across the pupil. On looking at a
black dot on a white card, the eye behind the prism sees
one image displaced upward and another downward ;
while with the other eye the dot appears in its true posi-
tion. If the muscular balance is perfect, the three images
are seen in line, the true image being just midway be-
tween the false images. Any lateral displacement of the
images indicates tendency to lateral deviation ; any verti-
cal displacement a tendency to vertical deviation.
To measure the extent of a latent squint prisms are
used. The prism that will rectify the displacement of
the false image indicates the amount of deviation present.
Such a prism being placed before the eye, no movement
of deviation or recovery occurs on covering or uncover-
ing. With the dark glass, such a prism causes the true
and false images to come together ; with the Maddox rod
it causes the streak to pass through the image of the
light ; with the Graefe test it brings the one dot directly
below the other ; with the double prism the true and false
images come in line and are equidistant.
The prisms furnished in the trial case are sufficient for
230 MEASUREMENT OF HETEROPHORIA.
the above tests. But special instruments have been de-
vised to facilitate such measurements by combining with
the Maddox rod or the Graefe test some form of rotary
prism.
The Stevens phorometer is such an instrument, bused
on the GraefS test, and fitted for the very accurate placing
of the prisms. The little instrument devised by the
author and illustrated in Fig. 84 combines the rotary
FIG. 84.— Phorometer combining Maddox rod and rotary prism.
prism with the Maddox rod. It measures slight devia-
tions with great accuracy; and up to 10 centrads.
Higher deviations must be partly corrected by a 10 or 20
centrads prism before the other eye, and then the remain-
ing deviation can be measured by this instrument.
Rotary deviation is rendered evident by use of a test
giving a linear image. Thus with the prism base up
or the double prism, a horizontal line is substituted for
the dot. If there is no rotary deviation of the eye, such
as has been spoken of when considering paralytic squint,
the true and the false images of the line remain parallel.
If there is rotary deviation, the image belonging to the
deviating eye will appear to be rotated in the opposite
direction. The lines of light given by two Maddox rods,
placed one before each eye, may also be used in the same
way; and the angle over which they must be rotated, to
make the two lines appear parallel, gives the amount of
rotary deviation.
DISORDERS OF OCULAR MOVEMENTS. 231
To discriminate between an insufficiency and a heter-
ophoria, the latent squint must be studied in different
parts of* the field of fixation. Usually it will suffice to
note the deviation with the eyes directed forward ; turned
strongly to the right (or face to the left), eyes turned to
the left (or face to the right) ; the eyes turned up (or head
thrown forward), turned down (head thrown backward) ;
and with the eyes turned to the ordinary position for
reading or other work.
In deciding on the proper course to be pursued with
reference to a case of latent squint, it is also important to
ascertain the amount of abduction, adduction, and sur-
sumduction (see p. 192).
This is most conveniently done with a rotary prism by
which any prismatic effect from 0 to 30 centrads may be
obtained. The form suggested by the author (see Fig.
FIG. 85.— Rotary variable prism.
85), measures even the smallest degrees of deviation with
great accuracy.
Treatment. — Where the latent squint is of moderate
amount and the. power of " overcoming " prisms with the
base in the direction of the deviation good, or where there
coexists a considerable error of refraction or other prob-
able cause for the symptoms, the tendency to squint may
be disregarded, at least until other factors in the case
have been looked after. In all cases where a notable
232 TREATMENT OF LATENT SQUINT.
error of refraction exists, its correction should take pre-
cedence of any operative treatment for the muscular faults.
In many cases heterophoria is an important indication
regarding the wearing of correcting lenses. Thus with a
moderate or low hyperopia the existence of two or three
centrads of esophoria emphasizes the need for the constant
wearing of correcting lenses.
If the latent squint is considerable (2 centrads or up-
ward of vertical deviation, 4 to 8 Cr. of divergence or
convergence), prisms should be tried. Prisms for this
purpose do not strictly " correct " a deviation, they allow
it without strain or inconvenience. Thus for exophoria
we use prisms with their bases toward the nose. These
allow the eye to turn out somewhat while still preserving
binocular vision. In general, the strength of the prisms
used in this way»should be such as to "allow" half of
the deviation ; but sometimes nearly the whole deviation
may be " allowed " with advantage.
If lenses are worn, the prismatic effect may be attained
with great accuracy, and with least expense, by decenter-
ing the lenses. When an eye looks through any part of
a lens, except its optical center, the effect is that of a
prism with its base at the thickest part of the lens. Thus
decentering a convex lens " in," or a concave lens " out,"
gives the effect of a prism with its base toward the nose.
Decentering a convex lens " up," or a concave lens " down,"
gives the effect of a prism with its base up. The pris-
matic effect increases as the optical center of the lens is
departed from. Thus by removing the optical center a
certain distance from the point where the visual line will
pierce the lens, any desired prismatic effect can be ob-
tained up to the limits of the strength of the lens and
the size of the glasses.
The greater the effect to be produced the greater must
be the decentering ; and the stronger the lens the less it
needs to be decentered. For all practical purposes the
number of millimeters of decentering required in any
given case may be found by the following rule ; multiply
the required centrads of deviation by ten, and divide by
DISORDERS OF OCULAR MOVEMENTS. 233
the strength of the lens in diopters. Thus to find the
decentering of a 4. D. lens necessary to produce 2 centrads
of prismatic effect 2X10-5-4 = 5 ram.
Systematic exercise of the ocular muscles by an
entirely different use of prisms is sometimes of great
value. For this purpose the prism is turned so as to
increase temporarily the work of the apparently weak
muscles, in the hope of thus securing a better develop-
ment and stronger action of them. Thus for right hyper-
phoria the eyes may be fixed on a distant object, and a
rotary prism be placed before the right eye with its base
up, making necessary an increased exertion of the muscles
that turn the right eye down or the left eye up. The
prism being turned so as to increase its effect, the patient
is told to keep the object looked at single as long as
possible. When doubling occurs, the prism is removed
or turned back, and the eyes permitted to rest a minute ;
then the exercise is repeated. For latent convergent
squint, the eyes may be made to fix a near-point, while
strong prisms are placed before them with the bases
toward the nose ; then the point of fixation is withdrawn
from the eyes until it appears double, .when the eyes are
allowed to rest. For insufficiency of convergence, prisms
with base toward the nose may be used. The fixing of a
point held at some distance from the eyes, which is then
gradually brought closer and closer until it is seen double in
spite of a strong effort, is also a simple and efficient exercise.
Operations on the ocular muscles, for latent squint, are
only to be considered after the most careful study of the
case and the faithful trial of other therapeutic measures.
They exert a powerful mental effect on the patient, which
is sometimes markedly beneficial. They break up for
the time vicious habits of using the eye-muscles with un-
necessary strain ; and they may change permanently the
state of the ocular balance, but not always with much
benefit to the patient. The extent of the permanent
mechanical effect cannot certainly be known beforehand,
or by testing at the time of operation, or immediately
afterward. Operation should only be resorted to for
234 OPERATIONS FOR HETEROPHORIA.
its mechanical effect when the extent of the latent lateral
deviation amounts to 10 centnuls (5 degrees) or upward,
or the vertical deviation to one half as much ; and where
the relief by the wearing of prisms has seemed to demon-
strate the connection of the symptoms with the latent
squint. Tenotomy may be done on the muscle which
tends to turn the eye too strongly in its direction, or
advancement upon its antagonist. The latter operation,
if done without complete division of the tendon or great
disturbance of neighboring parts, is the less liable to cause
untoward effects.
The extent to which the symptoms associated with
latent squint are really due to it is still uncertain. Often
the careful trial of all therapeutic measures is called for
in such cases. This must include the use of general
tonics, avoidance«of eye-strain, worry, overwork, or the
habitual use of such nerve-poisons as alcohol, tobacco,
tea, or coffee, particularly by young persons. Outdoor
life and physical exercise are also of great value.
Prognosis. — The permanent relief of the symptoms
associated with latent squint is often extremely difficult.
The most brilliant cases of apparent cure of symptoms
are liable to return to somewhat their original condition
in a few months or years. Those cases are most likely to
be cured in which the use of correcting lenses gives relief,
or in which it is possible to control favorably the manner
of living. A good many are rendered comfortable and
kept so by the use of the prisms, or decentered lenses,
which " allow " the squint.
SPASTIC SQUINT.
Deviations of the eyes due to spasm of the ocular mus-
cles attend hysterical seizures and some forms of brain-
disease. They may assist in the general diagnosis ; but
have little localizing value, and require no treatment
apart from that of their cause.
NYSTAGMUS.
Nystagmus is a slight, rapid, to-and-fro movement of
DISORDERS OF OCULAR MOVEMENTS. 235
the eyes, most frequently from side to side (lateral nystag-
mus) • but sometimes up and down or wheel-like (vertical
or rotary nystagmus]. Usually both eyes exhibit similar
movements. They may be increased by efforts to use
the eyes (intention nystagmus). It is commonly associated
with imperfect vision. It is often congenital, but may
arise in connection with disease of the central nervous
system, especially when that causes blindness. It often
occurs in miners who have to work in a poor light, with
the eyes directed obliquely upward (miners' nystagmus).
In most cases no interference with vision is occasioned
by the movements. But in miners' nystagmus, and in
some other cases where it comes on in adult life, it occa-
sions apparent movement of objects looked at, and annoy-
ing vertigo. When associated with high astigmatism, it
may grow less or cease entirely with the wearing of
correcting lenses. Recovery from miners' nystagmus
often follows change of occupation. In other cases little
improvement can be hoped for.
NODDING SPASM (SPASMUS NUTANS).
This is a nodding, lateral, or rotary movement of the
head, commonly accompanied by nystagmus, with which
it is closely allied. It usually appears during the first
year of life in rachitic patients. It is probably caused
by some ocular defect, or by keeping the child in a dark
room in which some bright spot is visible. The bright
spot quickly exhausts the portion of the retina exposed
to it, and the child changes the position of its eyes to
again secure a more vivid impression.
CONGENITAL DEFECT OF ABDUCTION WITH RETRAC-
TION OF EYEBALL.
In rare cases there exists from birth inability to turn
the eyes outward, commonly associated with retraction of
the eyeball when the eye is turned toward the nose. This
retraction may vary from 2 to 10 mm. On attempting
236 DISORDERS OF OCULAR MOVEMENTS.
to turn the eye in, there is often some narrowing of the
palpebral fissure, the lids being more widely separated
when the eye is turned direetly forward or the attempt is
made to turn it outward. One or both eyes may be
affected. The condition is largely due to an organic
defect in the external rectus, which may be replaced by
fibrous tissue. Little can be done to remedy such defects,
and ill-considered operations only make them worse.
DISEASE OF THE OCULAR MUSCLES.
Myositis. — Inflammation of the extra-ocular muscles
produces diplopia, pain in the orbit, exophthalmos, and
great impairment of ocular movements. It may be due
to syphilis, rheumatism, or to unknown causes.
True hypcrtrofky, and sclerotic changes with pseudo-
hypertrophy of these muscles, have been reported.
Rheumatism of their tendons of insertion is occasionally
noticed. It occurs in connection with acute articular
rheumatism, renders painful all ocular movements, may be
easily mistaken for episcleritis, and yields promptly to
anti-rheumatic remedies.
DISEASES OF THE CONJUNCTIVA. 237
CHAPTER IX.
DISEASES OF THE CONJUNCTIVA.
Hyperemia (Dry Catarrh}. — The appearance of
hyperemia of the conjunctiva has already been described
(p. 60). It is commonly attended with itching, smarting,
and burning, or the sense of a foreign body in the eye,
feeling worse after use of the eyes or exposure to heat.
Chronic hyperemia is indistinguishable from mild vernal
conjunctivitis.
Causes. — These are, for acute hyperemia, local irri-
tants, as dust or irritating vapors, excessive exposure to
the sun or strong winds, excessive use of the eyes, or
their prolonged use when tired, indulgence in alcoholic
beverages, gout, a general febrile condition, commencing
inflammation of the conjunctiva ; and acute catarrh of
the mucous membranes in general, especially of the nasal
mucous membrane. For chronic hyperemia one should
always search for a persistent, or frequently recurring,
cause. The most common of such causes are : eye-strain
from habitual overwork or the presence of ametropia ;
chronic hyperemia of the nasal and related mucous mem-
branes, including catarrh of the lacrimal passages ; re-
peated attacks of acute hyperemia ; prolonged exposure
to excessive heat ; and chronic alcoholism.
Treatment. — Acute hyperemia tends strongly to spon-
taneous recovery, and requires only removal of the cause,
rest for the eyes, and some soothing collyrium, such as a
solution of boric acid with or without borax. Chronic
hyperemia requires, first, the removal of the cause, and
if this prove insufficient, some of the milder forms of
treatment for chronic catarrhal conjunctivitis. The re-
moval of the cause, however, may include relief from
eye-strain, or long and careful general treatment, as to
overcome a general catarrhal tendency.
Acute Catarrhal Conjunctivitis (Simple Ophthal-
mia, Catarrh of Conjunctiva, Mucopurulent Conjunctivitis).
— When to hyperemia are added swelling of the conjunc-
238 ACUTE CATARRHAL CONJUNCTIVITIS.
tiva and conjunctival discharge, the case becomes one of
conjunctivitis.
Causes. — The causes include all those of conjunctival
hyperemia. The instillation of atropin or other mydriatic
causes or aggravates conjunctivitis in a few persons who
have such an idiosyncrasy. There can be no doubt that
certain pathogenic bacteria are the essential factors in the
causation of many cases of acute conjunctivitis. Among
the most important of these are the staphylococci, the
streptococci, the peumococcus of Frankel, and the so-called
xerosis bacillus. These are found in cases which must
still be classed together by their clinical characteristics.
The other organisms causing distinct clinical types of
disease are mentioned in the descriptions of those types
of conjunctivitis.
Symptoms. — The discharge of acute catarrh of the
conjunctiva is at first scanty and may be only apparent
by the adhesion of the lids in the morning, after it has
dried upon their margins throughout the night. It may
amount to but a slight increase of the normal secretion,
which is washed away by the usual or increased secretion
of the tears. As the case progresses the amount of dis-
charge increases ; and its character may vary to the
abundant flow of purulent conjunctivitis. Small masses
of the discharge may be noticed lying at the junction of
the lower lid and eyeball, or may be found in the lower
cul-de-sac of the conjunctiva, upon everting the lid.
The appearance of the lids varies with the degree of
hyperemia, the changes in the epithelium, and the amount
of exudation in the deeper tissues. The hyperemia gives
increased redness, which may appear only in the larger
number or larger size of the visible vessels. Thickening
of the epithelial layer masks the increase of redness and
gives the appearance of a gray film upon the surface of
the conjunctiva. Exudation into the deeper tissues, by
separating the vessels and by pressure upon them reduc-
ing their caliber, tends to diminish the redness, sometimes
to even less than the normal.
The pain of acute conjunctivitis is usually most marked
DISEASES OF THE CONJUNCTIVA. 239
early in the course of the disease, is strictly local, and
may vary from a slight discomfort to severe burning pain.
To some extent it is proportioned to the severity of the
inflammation, but it also depends somewhat on the condi-
tion of the nervous system. It resembles that of simple
hyperemia, and is described in many ways, but usually as
more or less of an itching, smarting, scratching, or burn-
ing character. It may be spoken of as aching, though
probably true aching when present is connected with consid-
erable swelling of the neighboring parts, or involvement of
the deeper tissues of the eyeball. In the early stages there
is often the exact sensation of a foreign body in the eye.
Exudation in conjunctivitis occurs within the tissues,
causing swelling, or upon their surface as discharge. It
is generally accompanied by loss of transparency, so that
the deeper details normally visible through the conjunc-
tiva are hidden. It involves largely the loose tissues
lying beneath the membrane, and if severe, affects the
whole thickness of the lids. On the eyeball the tissues
affected are thickest posteriorly where the membrane is
reflected upon the lids; hence, if the swelling be slight
or moderate in amount, it is most noticeable in this
region. If, however, the amount of serous exudate be
great, the pressure posteriorly tends to force it forward,
so that it raises up the conjunctiva to its attachment
around the cornea ; and the cornea appears surrounded
by a perpendicular or overhanging wall of translucent
tissue. This condition is called chemosis.
Careful examination of the affected tissue will often
show that it is the seat of numerous minute hemorrhages.
The swelling of the conjunctiva, however great, never
endangers the integrity of that membrane. But chemosis
is supposed by pressure to interfere with the zone of
vessels upon which the nutrition of the cornea depends ;
and the sulcus formed by it at the corneal margin cer-
tainly favors the retention of the discharges, and, in that
way, the infection of the cornea.
Discharge from the conjunctiva consists of increased
normal secretion and cast-off epithelium, with a variable
240 ACUTE CATARRHAL CONJUNCTIVITIS.
proportion of pus and micro-organisms. If the propor-
tion of pus be small, the masses found floating in the tears
will be gray or whitish in color and rather stringy in
appearance. As the proportion increases, the discharge
becomes more purulent in character, and sometimes is
decidedly so, even in cases that would be classed as
catarrhal conjunctivitis. At all times the apparent
amount of discharge and its consistence depend largely
on the extent to which it is diluted by the lacrimal secre-
tion. In the earlier stages the increased flow of tears is
liable to carry away all other discharges unnoticed. Later,
the secretion of tears is less copious, and the amount of
mucous or purulent matter appears relatively greater.
Diagnosis. — The hyperemia of conjunctivitis is to be
distinguished frogi that of keratitis, iritis, or glaucoma, etc.
(see p. 61). From other forms of acute conjunctivitis the
catarrhal often cannot be differentiated at the outset, except
that the symptoms are generally less violent than in puru-
lent or diphtheritic conjunctivitis. The differentiation
from more chronic forms must also wait until these have
time to develop their special characteristics. The bacter-
iological examination and identification of the organisms
present will in some cases be the only way of deciding
whether or not the case belongs in this class, or one of the
specific forms of conjunctivitis. The special clinical
characters of the other forms of conjunctivitis discussed
in connection with them furnish a basis for their differen-
tial diagnosis from this variety.
Treatment. — After the removal of the cause, so far as
it is removable, the treatment consists largely in rest and
cleanliness. The rest of the eyes should be supplemented
by general rest, if the inflammation be severe ; and should
always include sufficient sleep. Cleanliness is to be
secured by frequent bathing of the eye, with the free
instillation of a solution of boric acid and borax or sodium
chlorid, at intervals of from one to four hours, according
to the amount of discharge. Weak solutions of mercuric
chlorid, mercuric iodid, or oxycyanid may be used for the
same purpose. But in catarrhal conjunctivitis care should
always be taken to avoid solutions strong enough to act
DISEASES OF THE CONJUNCTIVA. 241
as irritants, their cleansing power being far more impor-
tant than their specific antiseptic influence.
Solutions of argyrol, 4 to 10 per cent., may be used at
short intervals. In the more severe cases, applications of
silver nitrate or protargol solution may hasten recovery.
The use of laxatives and appropriate remedies for any
coincident departure from general health may be needed.
Prognosis. — Most cases of acute conjunctivitis recover
completely in a few days. But when due to staphylococci,
the disease may persist longer. Lacrimal and nasal disease
must also be excluded before promising prompt recovery.
Influenza bacillus conjunctivitis occurs usually
in children in connection with influenza epidemics. The
discharge is abundant but watery.
Exanthematous Conjunctivitis. — The early stage
of measles, small-pox, scarlet fever, and some of the
other exanthemata is frequently marked by conjunctival
hyperemia and catarrh, to which the above name has been
given. It is characterized rather by hyperemia and swell-
ing without much discharge, although with measles and
scarlet fever the conjunctival secretion may even become
purulent, and in small-pox well-marked examples of the
eruption may be found, on the bulbar conjunctiva, espe-
cially near the corneal margin. Usually the conjunctival
trouble quickly subsides, but it may require treatment
even after the constitutional disease has run its course.
Acute contagious conjunctivitis is a specific dis-
ease caused by infection, the active agent being a small
bacillus first studied by Weeks, and which may be found
in the conjunctival discharges.
Symptoms and Course. — It begins two or three days
after infection, with glueing together of the lids and the
appearance of dry yellowish masses on their margins or
about the inner canthus, especially in the morning.
Hyperemia and discharge rapidly increase for two or
three days, and the discharge often becomes purulent.
The deeper fine vessels of the eyeball are much injected,
giving it a pink appearance. Hence the popular name of
u pink-eye." There is also usually some involvement of
the upper air-passages and adjoining sinuses, causing
16
242 ACUTE CONTAGIOUS CONJUNCTIVITIS.
slight coryza. The common course of the disease is to
complete recovery in a few days, but it may become sub-
acute and continue for several weeks. It appears to
spread by direct contact, extending to the different mem-
bers of a family, or through a school or barracks. It may
cause marginal ulceration or haziness of the cornea.
Diagnosis. — From catarrhs! conjunctivitis it can be
distinguished by the peculiar yellow secretion adherent to
the lashes, the occurrence of other cases in the same
house, either before or afterward ; and by the identifica-
tion of the Weeks' bacillus with the microscope. It is a
small bacillus resembling that of mouse septicemia. It
stains readily with methyleue blue, and loses its color by
the Gram method. It is found within the cells and also
free in the discharge. It is difficult to obtain in pure
culture, being generally mixed with a club-shaped non-
pathogenic bacillus.
A form of acute contagious conjunctivitis which many
observers have been unable to distinguish from the above
seems to be caused by the pneumococcus (Fraenkel) ; an
ovoid or lanceolate encapsulated coccus often found in
pairs, hence called the microcoecus lanceolatus (Talamon),
or the diplocoecus pneumonia? (Weichselbaum). It exists
in the normal saliva of many persons.
Treatment. — This will generally be similar to that of
acute catarrhal conjunctivitis. Cold applications may be
used the first two or three days. The more severe cases
should be treated by applications to the everted lids of a
2 percent, solution of silver nitrate, repeated every day
or two, until the discharge and swelling are markedly
diminished.
DiplobacilltlS conjunctivitis is characterized by
comparatively slight discharge, often only noticed by the
glueing together of the lashes after sleep. There is
moderate irritation and smarting, chiefly in the evening.
Many of the cases run a subacute or chronic course, ex-
tending over many weeks or months. The invasion is gener-
ally insidious, but the attack is sometimes acute ; and the
more severe cases may be taken for commencing trachoma.
DISEASES OF THE CONJUNCTIVA. 243
The palpebral conjunctiva and corners of the eye are
red. The discharge is gray, stringy in character, and
accumulates at the canthi. The disease is caused by a
diplobacillus first described by Morax and Axenfeld.
The treatment is the instillation of a solution of zinc
sulphate, J to 2 per cent., two or 'three times daily.
Gifford used zinc chlorid, ^ of 1 per cent., and Alt
a 2 per cent, solution of protargol. Treatment should be
continued at longer intervals for several days or weeks
after apparent recovery, to prevent relapse.
Ophthalmia nodosa is an inflammation of the con-
junctiva, sometimes extending to the deeper tissues of the
eye, due to the presence of caterpillar hairs. The con-
junctivitis tends to relapse again and again, and where
each hair is embedded, a rounded gray swelling is formed.
Excision of the offending particle, which may be extremely
minute, is the proper treatment.
Brief Recurring Bpiscleritis. — Under the name
Eplsderitis Periodica Fugax, Fuchs described a form of
conjunctival and episcleral hyperemia, attended with
pain, but without discharge ; lasting but a few days, but
recurring at intervals of a week to several months. In
some cases it lasts for many years. It seems to depend
on some obscure condition of the general system ; and is
little benefited by treatment.
Purulent Conjunctivitis. (Purulent Ophthalmia,
Acute Blennorrhea, Gonorrhea! Ophthalmia, Ophthalmia
Neonatorum). — This affection is characterized by great
swelling of the conjunctiva and lids, and abundant dis-
charge, at first serous and later purulent.
Cause. — In most cases this is the implantation upon
the conjunctiva of the gonococcus, by contact with fingers
or clothing carrying the infective material ; or by similar
contact in the birth-canal during labor. Disease clinically
similar may be produced by other pyogenic organisms.
Symptoms and Course. — Within one or two days after
infection the eye presents the symptoms of acute catarrhal
conjunctivitis, rapidly increasing in severity, with exces-
sive swelling of the lids and free discharge. This dis-
244 PURULENT CONJUNCTIVITIS.
charge is at first clear and watery, then it contains shreds
and flakes of mucus and may be discolored by blood.
Gradually it becomes more purulent, until it has the
appearance of typical creamy, or slightly greenish, pus.
The first indication of the gravity of the attack is found
in the severity of the symptoms and the rapidity of their
progress. The lids, in the early stage are tense, often
smooth and shiny. The swelling of the conjunctiva gives
rise to chemosis, and interferes considerably with the ever-
sion of the lids. When the discharge becomes purulent,
the lids generally become softer, and the swelling dimin-
ishes. In a few days the palpebral conjunctiva shows
hypertrophy of the papillae. Its surface becomes velvety
in appearance, and later may be obscured and covered to
a depth of two or three mm., with the pale, or dark-red
FIG. 86.— Papillary granulations of the late stage of purulent conjunctivitis,
shown on the everted upper lid, with severe hyperemia of the bulbar con-
junctiva.
granular masses. These are illustrated in Fig. 86. The
discharge, under treatment rapidly, or without treatment
more slowly, diminishes ; but several weeks are usually
required to restore the conjunctiva to an approximately
normal condition.
A common complication and the great danger of
the disease is involvement of the cornea. This has
been thought to depend chiefly upon the pressure of
the swollen lids, or the chemotic conjunctiva ; but it
may occur from direct infection by the virulent dis-
charge that bathes it, especially where this lies in
contact with the cornea, in the crease formed by the
overlapping of the swollen conjunctiva. When this occurs
a small ulcer forms near the corneal margin, which rapidly
DISEASES OF THE CONJUNCTIVA. 245
extends, both in area and in depth ; or a considerable
part of the cornea — usually at the center — rapidly be-
comes opaque and breaks down, leaving a large extending
ulcer. Such an ulcer is liable to cause perforation and
the serious or fatal results described under suppurating
ulcer of the cornea (Chapter X). In debilitated subjects,
or under inefficient treatment, the hypertrophy of the
conjunctiva above described is liable to be excessive and
to continue, with moderate discharge, for many weeks.
Varieties. — Gonorrheal ophthalmia the disease is called
when it is clearly due to infection with the virus of
gonorrhea, or the gonococcus is found in the discharge.
Cases of this character include the most serious and
dangerous cases of purulent ophthalmia.
Ophthalmia neonatorum is the name given to purulent
conjunctivitis in the new-born. Infection usually occurs
during birth, although some children are born with the
inflammation already developed, probably having been
infected after early rupture of the membranes in a slow
labor. A few cases also become infected subsequent to
labor, from lack of proper cleanliness. A majority of
cases, including all in which the inflammation is most
violent, show the presence of the gonococcus in the dis-
charge. Cases of ophthalmia immediately after birth do
occur that clearly have a different origin and character.
Diagnosis. — Purulent conjunctivitis is to be first sus-
pected from the violence of the symptoms of conjunctival
inflammation ; the extent and rapid progress of the swel-
ling ; and the free watery and flaky discharge. Con-
junctivitis coming on within four or five days after birth
should at once be regarded as probably purulent. In
adults the history of an antecedent urethral or vaginal
discharge, or exposure to contagion, can usually be
obtained. Later the profuse secretion of the thick pus is
very characteristic, and still later the existence of large,
soft, dark-red granulations, covering the inner surface of
the lids, is suggestive of the nature of the case.. Micro-
scopic examination of the discharges as described (p. 67),
stained with methylene blue, and also tried by the Gram
240 PURULENT CONJUNCTIVITIS.
method, may be necessary to decide the nature of doubt-
ful cases. Preparations so made may also be valuable in
regard to the medico-legal aspects of the case.
Treatment. — The most important point is the clean-
sing of the eye of all discharges as frequently as this
becomes necessary. In the earliest stage the free watery
discharge may so far accomplish self-cleansing that other
measures are of more practical importance. In healthy
adults, where the swelling is great, the application of cold
by pledgets of lint laid on a block of ice and thence
transferred to the lid, and changed every one or two
minutes, is often employed. When the swelling begins
to diminish, or the discharge to become markedly puru-
lent, cold is of less value. It must also promptly be
discontinued when haziness of the cornea shows that its
nutrition is beifig interfered with ; and is not to be
resorted to for weak patients. Cold is difficult to apply
efficiently in the purulent conjunctivitis of infancy, and is
not so beneficial.
When seen very early the course of the disease may
sometimes be modified by a single free application of a
strong solution of silver nitrate ; but during the period
of watery discharge and great tension of the lids, such an
application is not to be repeated.
As the disease passes into the stage of free secretion
of pus, the thorough and frequent cleansing of the eye
becomes of the highest importance. All discharge escap-
ing from the palpebral fissure should be promptly removed
with absorbent cotton, which will take it up without un-
necessary wiping of the lids. As often as every hour at
the height of the disease, or even more frequently if the
discharge is very profuse, the conjunctival sac should be
thoroughly washed out, and all shreds clinging to its sur-
face be removed with absorbent cotton. For such washing
the solution may be of boric acid, or very weak solutions
of trikresol, potassium permanganate, mercuric chlorid or
cyanid, or formaldehyde. The important points an- that
it shall be used freely and efficiently, and shall not be so
strong as to act the part of a local irritant. In any case
DISEASES OF THE CONJUNCTIVA. 247
the water is the more important ingredient of the solu-
tion ; and the object to be aimed at is the complete
mechanical removal of discharges, rather than their de-
struction or neutralization in situ by the chemical anti-
septic. For such washing, various irrigators in the form
of hollow lid elevators, or specula, perforated for the
escape of the solution, have been devised ; but no instru-
ment will be efficient without careful thoroughness in its
use ; and the rubber-bulb pipette will do as well. It
should have a perfectly smooth nozzle, and as large a
bulb, up to one or two ounces, as is obtainable. The
point of the tube is to be inserted between the lids near
the outer commissure, and the solution forced" into the
eye. Care must be taken to provide for the subsequent
disinfection of the tube when allowed to come in contact
with the lids, as by allowing it to stand in a stronger
antiseptic solution in the intervals. As the discharge
becomes less, the intervals between the washings may be
lengthened. But it must be insisted that the frequent
gentle but thorough cleansing of the eye is of more im-
portance in this disease than all other remedial measures
taken together.
As the secretion becomes purulent applications of
2 to 4 per cent, solutions of silver nitrate, or 20 to 40
per cent, solutions of protargol to the conjunct! val sur-
face of the everted lids are indicated. Such applica-
tions may be repeated daily, occasionally even oftener,
or at longer intervals. The rule must carefully be
observed not to repeat the application of the nitrate until
the red and rather raw appearance of the lid, which
may be noticed for some hours after an application, has
given place to the usual succulent appearance character-
istic of the disease. The applications of such solutions are
to be continued at lengthened intervals until the cure of
the case is nearly complete, or the condition has changed
into one of chronic conjunctivitis. In addition a 2 per
cent, solution of protargol may be instilled every two or
three hours.
Where the swelling of the lids is very great, preventing
248 PURULENT CONJUNCTIVITIS.
their free eversion and complete cleansing, and causing
considerable pressure upon the eyeball, canthotomy should
be practiced ; or in infants, the upper lid may be divided
by a vertical incision (see Chap. XIX).
For debilitated patients the application of heat, either
by cloths wrung from water of a temperature of 130° F.
or upward, or by the hot-water coil, or the Japanese hot-
box, must replace the application of cold that might be
resorted to in the more robust. When involvement of
the cornea is noted, such applications of heat must
replace cold in all cases. To be effective the application
of cold must be continuous ; but high degrees of heat may
be used for short periods, five to twenty minutes, with
intervals of three to four hours during which the eye is
kept moderately warm. Especial treatment directed
toward the corn*al complications will be referred to
in Chapter X, on Diseases of the Cornea.
The general treatment may include rest in bed until
the swelling and discharge are beginning to subside.
Internally it is well to commence with a free laxative or
decided cathartic, and subsequently to give quinin and
tincture of the chlorid of iron, the latter in full doses.
If the patient be debilitated, other tonics and stimulants
may be indicated to keep up the nutrition of the cornea.
Pain, if severe, may be met with small doses of morphin
or acetanilid.
Prophylaxis. — Scarcely secondary in importance to the
treatment of this disease are certain precautions for its
prevention. In adults, usually but one eye is affected in
the beginning, and the greatest care should be taken to
avoid the conveyance of the virus to the second eye. To
more certainly prevent this, when the first eye seems
likely to be lost, it is advisable to close the second eye
with an impervious dressing. Linen may be placed upon
the lids, over this a compress of absorbent cotton, and on
this some protective, the whole to be retained by collodion
painted all around the margin of the dressing. If it be
important for the patient to be able to see, this dressing
may be replaced by a large watch-glass made fast at its
DISEASES OF THE CONJUNCTIVA. 249
margin by strips of adhesive plaster. This is called
Buller's shield, from the name of its proposer. Knapp
uses a piece of mica, and leaves the temporal margin free
for circulation of air. Through it the patient can have
the use of the sound eye, and the surgeon can watch for
any indications of disease, while the chances of infection
are reduced to a minimum.
At birth it commonly happens that both eyes are in-
fected during the passage of the head through the vagina,
but even after this has occurred the outbreak of the dis-
ease may- be prevented. To accomplish this the child's
eyes should be immediately cleansed, and a 2 per cent,
solution of silver nitrate freely instilled. If this precau-
tion, known as the Crede method, be adopted, the disease
will generally be prevented. So grave a calamity is
blindness from purulent conjunctivitis that the use of
this precaution has been urged at the birth of every child.
Such a general application is not desirable, since it
might do harm in unsuitable cases; but it should be borne
in mind and resorted to whenever there is a probability
that the mother is infected with gonorrhea.
The importance of this matter may be appreciated
when it is remembered that a large proportion of all causes
of blindness operate only in adult life or old age, while
this entails blindness from infancy. Even when there
seems no chance of infection, the appearance of redness
or discharge in an infant's eyes should at once command
the attention of those in charge of it.
Prognosis. — In few diseases does prognosis depend so
much upon treatment. Efficient treatment, begun early
enough, will save the eye in almost all cases of ophthal-
mia neonatorum, and in a large proportion of the violent
cases of gonorrheal ophthalmia in adults. If, however,
the patient's general nutrition and resisting power are
much below the standard, a purulent conjunctivitis of
very moderate severity may cause general opacity or
sloughing of the cornea. In such cases this is liable to
occur late. In otherwise healthy subjects, if the cornea
remain clear until the discharge has begun decidedly to
250 PURULENT CONJUNCTIVITIS.
diminish, there is a very strong probability that it will
escape damage. If the conjunctiva alone is involved,
recovery is complete.
Croupous Conjunctivitis (Plastic Conjunctivitis,
( 'ronpous Ophthalmia). — In certain cases commencing as
violent catarrhal or purulent conjunctivitis, the plastic
material thrown out upon the surface of the lids, instead
of being carried off in flakes by watery discharge, remains
adherent as a gray rather soft layer that can be removed
by rubbing or with the forceps, leaving the lid-surface
red and bleeding at certain places. A deposit of this
kind may occur in severe catarrhal, acute contagious or
mild purulent conjunctivitis. After some days, the mem-
brane deposited separates spontaneously, leaving the sur-
face of the conjunctiva much the same as in the later
stages of severe catarrhal inflammation.
The prognosis is rather favorable, deposit is usually
confined to the surface of the lids, and the cornea rarely
becomes involved. The diagnosis between this condition
and diphtheria of the conjunctiva will be considered
under the latter heading.
The treatment should include the cleansing and
general measures appropriate for a mild case of purulent
conjunctivitis. But cold is to be avoided, and hot appli-
cations used instead. The membranous deposit should
be left undisturbed, and applications of silver nitrate
should not be tried until the false membrane has dis-
appeared.
Diphtheria of the Conjunctiva (Diphtheritic Con-
junctivitis.)— When on everting the lids in a case of com-
mencing conjunctivitis, one finds parts of their inner sur-
face pale gray, infiltrated with rigid material that strongly
resists the manipulation of turning the lids, and the sub-
conjunctival tissue all infiltrated, diphtheria of the con-
junctiva must be suspected, although it is a rare disease.
Symptoms and Course. — In such a case the lids are
tense, greatly swollen, and are very much more rigid
than they would be from the same amount of swelling in
connection with purulent conjunctivitis. It may be quite
DISEASES OF THE CONJUNCTIVA. 251
impossible to evert them. The paler areas of the con-
junctiva mark the greatest infiltration and shutting off
of blood-supply. While the surface of the conjunctiva
may be covered with a false membrane similar to that
which forms on the tonsils, this may be quite absent;
the fibrinous exudate being situated within the tissues.
As the case progresses, the whole lid may become the
seat of the rigid infiltration, which may extend to the
ocular conjunctiva. The eye is painful, the lids hot and
red. For several days the rigid infiltration continues,
then it begins to soften, and the affected tissue is very
apt to slough. The discharge is at first watery, later
becoming turbid with fibrin and effused blood, and puru-
lent or mucopurulent in the stage of softening. The
local process is accompanied by fever and general depres-
sion, such as mark the course of diphtheria elsewhere.
The cornea is apt to become affected early, and to
break down rapidly and be partially or totally destroyed.
The sloughing of the lids is liable to cause adhesions
between them and the eyeball (symblepharon).
Cases occur in which the firm infiltration of the lids is
entirely absent, the symptoms being in the main those of
catarrhal conjunctivitis. But the cornea rapidly breaks
down, and the microscope shows the presence of the
Klebs-Loffler bacillus.
Diagnosis. — The recognition of typical diphtheria of
the conjunctiva should not be difficult. The rigidity of
the lids in excess of that ordinarily noticed, with the
same amount of swelling, and the gray patches of stran-
gulated tissue, which may run together and include the
whole surface of the conjunctiva up to the corneal mar-
gin, are unlike anything seen in purulent or catarrhal
conjunctivitis. As compared with croupous conjuncti-
vitis, the condition is entirely distinct. In croupous con-
junctivitis the membrane is situated upon the surface,
somewhat like the membrane of diphtheria in the phar-
ynx, while in diphtheria of the conjunctiva there may be
no membrane upon the surface, or it is less noticeable
than the rigidity of the deeper tissues. In general the
252 DIPHTHERIA OF THE CONJUNCTIVA.
diagnosis is to be established by finding of the Klebs-
Loffler bacillus ; but it should be remembered that the
so-called xerosis bacillus, which may very generally be
obtained from the normal conjunctiva (and which prob-
ably has no connection with xerosis) resembles so closely
the true diphtheria bacillus that they cannot be certainly
distinguished except by culture experiments and their
effects on the lower animals.
Treatment. — Diphtheria of the conjunctiva is to be
recognized as essentially the same disease as diphtheria
of the pharynx or larynx, and is to receive the same
general treatment. It is of the highest importance that
it should be promptly recognized, and treated by full
injections of the diphtheria antitoxin, repeated at inter-
vals of not more than sixteen hours (Standish). The
results of this line of treatment applied early have been
almost universally satisfactory, and its importance over-
shadows that of all local remedies. Locally cold may be
applied, if swelling of the lids is great, the patches of
gray, rigid infiltration small and few, and the cornea not
infected. If, however, much of the tissue is being stran-
gulated by excessive fibrinous infiltration, or the general
condition of the patient is one of depression, or the cornea
shows signs of infiltration, cold is to be avoided, and hot
applications made as described for purulent conjunctivitis.
In any case, the cold should be limited to the first day of
the attack ; and subsequently, heat continuously applied
to favor the softening of the lids with the least possible
sloughing of tissue. Careful cleansing of the conjunctiva
is important. After the process of softening, a solution
of silver nitrate may be applied, at first very cautiously,
to the inner surface of the lids. If only one eye is in-
volved, the other should be carefully protected from
infection, as in purulent conjunctivitis. During the
attack, and subsequently, such general remedies as
tincture of the chlorid of iron, free stimulation with
alcohol, and the use of strychnia, will be indicated.
Prognosis. — The chance of saving an eye affected
with the disease depends largely on the prompt resort to
DISEASES OF THE CONJUNCTIVA. 253
the use of the antitoxin. Without it a very large propor-
tion of eyes have been destroyed by the sloughing of the
cornea. Under its use, nearly all reported cases have
terminated in recovery.
Chronic Membranous Conjunctivitis. — Rare cases
occur, chiefly among children, in which with some swell-
ing and slight conjunctival discharge, there are found, on
everting the lids, extensive patches of grayish or whitish,
tough, firmly adherent membrane, the removal of which
leaves a raw bleeding surface. There may be no great
interference with the use of the eye ; which, except for
the swelling of the lid, would look normal. This condi-
tion may continue for months, or even years, without
material change. The removal of the membrane is
promptly followed by its renewal. Sometimes but one
eye is involved ; but both are liable to become affected.
In connection with this condition, there arise acute exacer-
bations, in which the cornea may slough and the eye be
lost. The connection of this condition with acute diph-
theria is uncertain. Repeated examinations have some-
times failed to discover the Klebs-Loffler bacilli ; and
in other cases they were only discovered during acute
exacerbations. No treatment has been found to cut short
the disease or greatly influence its course.
Chronic Catarrhal Conjunctivitis. — Repeated
attacks of acute catarrhal conjunctivitis, or the persistent
action of influences that tend to cause acute conjunctival
inflammation, as eye-strain, habitual exposure to irritant
dust or vapors, or artificial heat, chronic disease of the
lacrimal passages with regurgitation of mucopurulent
discharge into the conjunctiva, are among its common
causes.
Symptoms and Varieties. — Chronic catarrhal con-
junctivitis affects chiefly the palpebral portions of the
conjunctiva, extending in bad cases or acute exacerba-
tions to the ocular portion. These exacerbations arise
from whatever increases the hyperemia of the parts.
The surface may be slightly reddened and roughened, by
the enlargement of the papillae, constituting the so-called
254 CHRONIC CATARRHAL CONJUNCTIVITIS.
"granulated lids," which are something very different
from granular conjunctivitis. The discharge consists of
only a few shreds of mucopurulent matter, which may
collect at the canthus ; or, during the closure of the lids
at night it may, by drying on the lashes, glue them
together so that some force is required to open the eyes
in the morning. The eyeball may be perfectly normal
in appearance or may present only a few dilated veins.
A common form of disease affects old people who live
in bad hygienic surroundings. There is little or no dis-
charge, and the entire surface of the lids remains smooth.
The epithelial layer is apparently thickened, so that the
conjunct! val surface of the lid presents the appearance of
purplish-red covered with a gray film. This form of the
disease is attended with a great deal of smarting and
burning, on account of which the patient usually seeks
relief, and is willing to undergo prolonged treatment.
Diagnosis. — The diagnosis of chronic catarrhal inflam-
mation of the conjunctiva is to be made from the history
of the case, the appearances above described and the
absence of symptoms characterizing other forms of chronic
conjunctival disease, which will be referred to in connec-
tion with those diseases.
Treatment consists of: First, removal of the cause, if
this be possible ; as the relief of the eye-strain by glasses,
change of occupation or residence when the disease is due
to habitual exposure to some irritant; or removal of
lacrimal obstruction. If there is considerable thickening
of the lids, or discharge, they may occasionally be bathed
for two or three minutes with very hot water. The
local applications should include some rather strong
astringent, as a solution of silver nitrate ^ to 1 per cent.,
a solution of tannin in glycerin, or crystal of alum,
applied to the surface of the everted lid. Where such
applications cannot be made at intervals of two or three
days, a solution of zinc sulphate ^ to ^ per cent, may be
given to be dropped into the eye once or twice daily. In
a very mild case boric acid solution may answer best.
For decidedly chronic cases, either alone or in connection
DISEASES OF THE CONJUNCTIVA. 255
with the astringents mentioned, an ointment of yellow
oxid of mercury should be used once daily.
Prognosis. — This disease can last indefinitely ; and
often the cure will depend entirely upon the removal of
the cause. If, however, the condition has lasted for
years, some of its effects are likely to persist in spite of
any treatment. The chronic conjunctivitis of old people,
attended by smarting, is commonly not completely cur-
able ; but is capable of alleviation, which is usually highly
appreciated.
Parinaud'S conjunctivitis is a rare disease character-
ized by a severe onset, great swelling of the lids, polypoid
granulations of the conjunctiva, involvement of the neigh-
boring lymphatic glands, and ultimate recovery. It
affects commonly but one eye, attacks children and adults,
and the onset is attended with slight rigors and severe
general depression. The disturbance and swelling of the
pre-atiricular, sub-maxillary, and cervical lymphatic
glands of the affected side are marked ; and sometimes
these go on to suppuration. If the granulations are not
very numerous, they may be cut off and their bases cauter-
ized. Other treatment seems to have but little effect, but
the case goes slowly on to recovery.
Vernal Conjunctivitis (Spring Catarrh, Fruhjahr
Catarrh). — This is a rather rare disease, affecting children
and young persons, recurring year after year, during the
summer. The more marked cases begin in the spring
and last until cool weather in autumn. After some years
the attacks become less severe, and finally may cease
altogether.
Symptoms and Course. — The inner surface of the lid
presents a general redness, with enlargement of tjhe
papillae. In typical cases there is the appearance of the
blueish white film, like a thin layer of milk, spread over
the conjunctival surface. Both eyes are affected, though
sometimes one more than the other. In a considerable
portion of the cases the ocular conjunctiva appears nor-
mal. In typical cases, however, it presents hyperemia,.
and at the corneal margin a plicated thickening and in-
256 VERNAL CONJUNCTIVITIS.
creased redness, which may. be pigmented. There is con-
siderable smarting pain and increased lacrimation during
the height of the attack.
In the palpebral form, the epithelial layer may be
greatly thickened, and large flattened masses appear on
the tarsal portion of the upper lid, especially toward its
posterior margin. Bad cases remain troublesome through-
out the year, becoming aggravated in the warm season.
Treatment. — No plan of medicinal treatment, either
general or local, can be relied on to cut short the disease.
The discomfort can often be diminished by cutting off the
larger masses of thickened epithelium, or local applica-
tion of yellow oxid of mercury ointment, solutions of
tannin or sodium hyposulphite, 5 to 10 per cent. The
X-rays sometimes»cause marked improvement, but cannot
be relied on to cure the disease. Where possible, the
patient should spend the summer in a cooler climate, as
at the mountains or seashore. Any excess of clothing
should be avoided and diet carefully attended to.
Prognosis. — The prognosis as to ultimate recovery
without permanent damage is good, but the duration of
the attack cannot be foretold, and there is a liability to
recurrence of the trouble year after year.
Follicular conjunctivitis is a form of subacute or
chronic conjunctivitis in which pale, translucent follicles,
or masses are found in the folds of the conjunctiva where
it passes from the globe onto the lid. The appearance
of the follicles is very noticeable in comparison with the
hyperemia present. The condition is essentially a catar-
rhal conjunctivitis, and amenable to the same treatment.
But the presence of the enlarged follicles justifies its
separate classification to emphasize its difference from
trachoma.
Trachoma (Granular Conjunctivitis, True Granular
Lids, Chronic Blennorrhea, Chronic Ophthalmia, Egyptian
Ophthalmia) is a specific inflammatory disease of the con-
junctiva, arising from infection, and running an extremely
chronic course. Its bacterial cause is still uncertain, but
the contagion exists in the secretions. It arises under
DISEASES OF THE CONJUNCTIVA. 25*7
bad hygienic conditions, and where people are crowded
together, as in the steerage-passage across the ocean, in
barracks, schools, and orphan asylums. From such cen-
ters of contagion it extends in communities that present
favorable conditions for it by reason of overcrowding or
lack of cleanliness. Race exerts an important influence,
it being common among the Italians, Irish, and people
of Northern Europe, and very rare among American
negroes. Climate, and probably the amount and charac-
ter of the dust in the atmosphere, have some influence
upon it. But it is not, as some have supposed, only found
at low altitudes.
Symptoms and Course. — Many cases arise insidiously,
so that the patient does not recognize that there is any-
thing the matter until the case is well developed. In a
majority, however, the first effect of the specific virus is
an inflammation that cannot be distinguished from acute
catarrhal, or purulent conjunctivitis. Such inflammation,
however, declares its character by running a slower
course, with gradual thickening of the conjunctiva and
deeper tissues, moderate mucopurulent discharge, and the
progressive development of the characteristic granula-
tions. These granulations vary in size, from the smallest
perceptible to three or four mm. in diameter. They are
more or less deeply embedded, but mostly protrude some-
what. Their appearance is illustrated in Fig. 87.
FIG. 87.— Trachoma, showing the trachoma-granules on the everted upper
lid, with pannus extending on the upper part of the cornea to below the mar-
gin of the pupil.
They have the gray color and translucency of sago
grains, when partly soaked in water. They are largest
where the conjunctiva passes from the eyeball to the lids.
17
258 TRACHOMA.
The entire surface of the lids, particularly of the upper,
may be studded with them; but they are never massed
together and mutually compressed, like the papillary
granulations seen after purulent conjunctivitis (see Fig.
86). They are much larger than the papilla? of chronic
conjunctivitis, and their presence in other parts than the
retrotarsal folds distinguishes them from the enlarged
follicles of follicular catarrh.
As the entire surface of the lids becomes seriously in-
volved and considerably roughened, corneal complica-
tions are apt to arise, endangering the sight. These are
described under the headings of pannus, corneal ulcers,
and opacities (Chapter X).
The full development of typical granulations and cor-
neal complications usually requires several weeks or
months. When tnis stage has been reached the case may
remain without essential change for years. In a majority
of cases the trachoma granules, which consist of masses
of leukocytes, undergo partial organization into connective
tissue. The contraction of this tissue may stop the for-
mation of granules, but always leads to deformity of the
lids. Ultimately all appearance of the granules may van-
ish and the entire surface of the lids become smooth,
presenting the appearance of chronic catarrhal conjuncti-
vitis, and only the sequels of the disease, lid-deformity,
conjunctiva! contraction, and corneal irregularity, may
remain. These will remain, however, throughout life.
The above description refers to a typical case of tra-
choma. Each feature included in it may at some time
be lacking. In some cases that appear, from association,
to be due to trachoma virus, the granules never develop,
the case running the course of a chronic catarrhal con-
junctivitis with considerable discharge, and perhaps with
involvement of the cornea. In a considerable portion of
cases, the disease, although characterized by well-devel-
oped trachoma granules, seems to give little or no dis-
comfort a large part of the time, the patient only noticing
its existence during the exacerbations of acute inflamma-
tion, which occur at intervals. Occasionally these cases
DISEASES OF THE CONJUNCTIVA. 259
go on to an enormous, almost horny thickening of the lids,
before seeking treatment. In a few patients without
efficient treatment, and in a large proportion under such
treatment, the disease runs its course in a few months
without involving the cornea, and leaves but very slight
contraction of the conjunctiva, or deformity of the lids.
In other cases the inflammation is intense, the discharge
excessive, the cornea becomes involved early, and only
prompt and vigorous treatment can prevent complete
blindness. In some cases the trachoma granules, although
present, are deeply embedded beneath the thickened
opaque conjunctiva, or in the masses of fibrous tissue
that have developed in the lid, so that they are not seen.
Diagnosis. — The presence of the typical trachoma
granules already described scattered over the surface of
the lids is sufficient to establish the diagnosis. If they
are confined to the retrotarsal fold, the case may be
merely one of follicular catarrh. Involvement of the
cornea with a history of catarrhal conjunctivitis, and
marked cicatricial contraction, is also characteristic. In
the early stage marked objective changes, in the conjunc-
tiva with little discomfort point toward trachoma. Some-
times the termination of the case must be known before
a diagnosis can be arrived at. The history of oppor-
tunity for infection is a valuable indication. But the
patient's statement as to the duration of his trouble is
often very erroneous.
Treatment. — In the early stage, before the granules
have developed sufficiently to render the diagnosis posi-
tive, applications of silver nitrate may be resorted to.
Whenever the granulations are noticeable, or if they
exist hidden under the conjunctiva or in the thickened
lid, the progress of recovery will be hastened by mechani-
cally pressing out the granules. This may be done with
the thumb-nails, catching the thickness of the lid, or a
fold of its inner surface, between the two nails, and by
firm pressure forcing out all that can be so removed from
its tissue. It is better done writh some form of forceps
made for the purpose. Those of Prince have smooth
260 TREATMENT OF TRACHOMA.
fenestrated jaws, with which one or more of the granules
are caught, and by a pull of the forceps pressed out. But
the writer prefers the roller-forceps of Knapp, by which
the contents of the granules are pressed out, as water is
pressed out of clothing by a wringing machine (see
Chap. XIX).
In a few cases the mechanical removal of the granular
contents from the lids may be followed by full recovery
without further treatment ; but in the large majority of
cases it only hastens the recovery, which must be brought
about by astringent applications,' faithfully continued as
long as necessary. Removal of the trachoma granules has
been effected by free incisions, scraping, or brushing,
(grattage and brassage) ; but these methods are not more
efficient than expression, and are more likely to be fol-
lowed by excessiv^ cicatricial changes.
For cases in which the lids contain little or none of the
granular material, the application of astringents is to be
relied upon.
These must be thoroughly applied to the whole affected
surface of the everted lids, any excess being washed away
or neutralized. Among such applications, that of the
crystal of copper sulphate (Milestone) has been found
most beneficial. At the height of an attack it may be
applied every day ; but usually every second or third day
is sufficient. Next to it in general usefulness the writer
would place the solution of tannin in glycerin. This
latter application is more useful when the discharge is
slight and the conjunctiva comparatively smooth. Where
the thickening is chiefly in the conjunctiva and the dis-
charge considerable, solutions of silver nitrate are most
beneficial. A solution of iodin in glycerin or in liquid
petrolatum, applied to the everted lids every day or two,
has a very decided curative effect. The application of a
strong solution of mercuric chlorid has been highly
recommended. A solution of 1 : 500, or even stronger,
may be brushed over the conjunctiva, and all excess
washed away ; but such an application is quite painful.
Excision of the affected retrotarsal fold and of the tarsus
DISEASES OF THE CONJUNCTIVA. 261
is proper in some cases. Applications of the X-ray and
radium are credited with some cures, but fail to control
the bad cases. The eyes should be kept cleansed of any
noticeable discharge by solutions of boric acid or trikre-
sol. In the more chronic cases, the correction of marked
errors of refraction may exert a beneficial influence ; and
in any case, the avoidance of dust or of a smoke-laden
atmosphere will be helpful. An important part of the
treatment is that of the alterations produced in the cor-
nea and the lids. These will be considered under their
respective headings. But if the palpebral fissure is mark-
edly contracted, interfering considerably with the ever-
sion of the lids for treatment, a canthotomy, or better, a
canthoplasty, should be done to increase the efficiency of
local applications. If displacement of the lashes is such
as to cause them to rub against the cornea or conjunctiva,
their restoration to normal position may be a necessary
part of the treatment.
Prognosis. — Treatment must usually be continued for
months, often for years. It is impossible to foretell when
it may be safely stopped, and premature suspension will
be followed by relapse. In all but the mildest cases,
noticeable cicatricial changes in the conjunctiva and lids
will remain.
Petrifying Conjunctivitis. — This is a rare chronic
disease, characterized by chalk-like deposits which cause
white spots in the palpebral conjunctiva, each surrounded
by a reddened, swollen zone. Most cases end in recovery,
but the eyeball may become involved and the eye lost. It
does not seem to be contagious, and the cause is unknown.
Phlyctenular Conjunctivitis (Phlydenular Kerato-
conjunctivitis, Phlyctenular Ophthalmia, Strumous or
Scrofulous Ophthalmia, Conjunctivitis Lymphatica). — This
affection is excited by many of the causes of catarrhal
conjunctivitis. It occurs chiefly in children with an
underlying tendency to catarrhal affections of all mucous
surfaces, eczematous eruptions, and glandular enlarge-
ments.
It is characterized by chronic hyperemia of the pal-
262 PHLYCTENULAR CONJUNCTIVITIS.
pebral conjunctiva ; and recurrent exacerbations, includ-
ing the development of phlyctenules on the ocular
conjunctiva and cornea and occasionally on the palpebral
conjunctiva, with symptoms of acute conjunctivitis.
Symptoms and Course. — The phlyctenular attack
usually begins with irritability of the eyes, photophobia,
and excessive lacrimation. In one or two days there develop
on some portion of the ocular conjunctiva, usually the
corneal margin, or upon the cornea itself, vesicular eleva-
tions with a red and swollen base. The vesicle, or phlyc-
tenule, quickly becomes an ulcer, the contents escaping.
The deeper swelling causes the ulcer to appear elevated
above the general surface. The redness which is most
intense in a limited sector of the conjunctiva, running
forward to the phlyctenule (see Fig. 17), continues to in-
crease for two or» three days and becomes general. The
discharge is slight and is washed away in the excessive
flow of tears. In a severe attack, a crop of phlyctenules
may be scattered all around the margin of the cornea.
At the height of the attack, the whole of the conjunctiva
may be hyperemic and thickened. In a few days this
general redness subsides, but the sectors of enlarged ves-
sels running out to the region of the phlyctenules, con-
tinue some days longer. These with the swollen tissue
of the phlyctenules, gradually return to normal, the
whole attack lasting from one to three weeks, unless pro-
longed by the formation of a corneal ulcer. The photo-
phobia is often so severe that the child buries its head in
a pillow and refuses to use its eyes, even in a darkened
room.
Before the termination of the first attack a second may
begin, so that the eye is kept continually red and painful ;
or there may be an interval in which the eye is appar-
ently normal before the trouble recurs. During the
interval the inner surface of the lids will be found
hyperemic, the visible vessels being larger and more
numerous than normal, and there may be a slight con-
junctival discharge causing adhesion of the lids in the
morning. lu the attack the conjunctiva is always in-
DISEASES OF THE CONJUNCTIVA. 263
volved, but the danger of the prolonged inflammation
and damjtge to the sight lies in the involvement of the
cornea (see Chap. X). The conjunctival affection will, in
time, if not aggravated by injudicious applications, end
in recovery, with restoration of a smooth but sometimes
slightly contracted membrane.
Diagnosis. — The diagnosis from acute catarrhal con-
junctivitis rests on : the distribution of the hyperemia
(see p. 61), the occurrence of the phlyctenules or the
ulcers that succeed them, the excessive photophobia and
lacrimation, the history of previous attacks, and the pres-
ence of enlarged vessels in normally transparent tissue on
the inner surface of the lids. To make a satisfactory
examination of a child's eyes, it will often be needful to
put it in the position for making applications to the con-
junctiva, and sometimes to use a lid elevator. The
habitual tight closure of the lids frequently gives rise to
a macerated condition of the skin near the outer canthus,
with the formation of fissures or rhagades radiating from
the outer canthus.
Treatment. — Every case of phlyctenular conjunctivitis
requires the careful consideration of the general nutrition,
and of local influences outside of the eye and its imme-
diate appendages. A proportion of cases will recover
without other treatment if placed on proper diet. This
should consist largely of milk and well-cooked farinaceous
foods. The strict prohibition of tea or coffee, and fried
foods is very important ; and the restriction of sweetmeats,
cakes, and candy, which should be taken only at the close
of a meal and with plenty of water. Care of the diet
may be supplemented by the administration of remedies
addressed to the alimentary canal, as small doses of
calomel, followed by some other laxative, and the digest-
ants where indicated.
Next in importance is the careful treatment of the
nasal passages. These will often present a chronic thick-
ening and hyperemia of the mucous membrane, which,
although often but another expression of the general dis-
order, especially hinders the return of the conjunctiva to
264 PHLYCTENULAR CONJUNCTIVITIS.
normal, and should receive appropriate local treatment,
including cleansing, alterative applications, as iodin, com-
pound tincture of benzoin, etc., and spraying with liquid
petrolatum.
Where the patient presents distinct evidence of glandu-
lar involvement and anemia, general tonics, especially
syrup of iodid of iron, or hydriodic acid, with quinin,
should be given. Local treatment to the eye is not less
important. Of greatest benefit are applications of the
ointment of yellow oxid of mercury, commencing with
a weak preparation, and increasing its strength until the
application causes some little smarting. The ointment is
to be applied once daily, usually at bed-time, by drawing
down the lower lid and placing with'i it a piece the size
of a grain of rice or slightly larger. The eye is then
closed and the cloted lids are rubbed over the globe, until
the drug has been diffused to every part of the conjunc-
tiva ; and the portion escaping between the lids is rubbed
well into their margins.
If the inflammation of the conjunctiva is severe, appli-
cations of a solution of tannin in glycerin should be made
every two or three days to the everted lids. The use of
the mercuric oxid must be continued during the intervals
between the attacks, and occasionlly for weeks or months
after the eyes seem free from inflammation. In the more
severe chronic cases it is well, also, to continue the appli-
cation of glycerin and tannin. Where the photophobia
is severe, the fissures in the skin of the lids near the outer
canthus greatly aggravate the trouble. These should be
touched either with tannin in glycerin, or with 1 or 2 per
cent, solution of silver nitrate. The making of applica-
tions to the lids in these cases is often somewhat difficult ;
and the means for assuring efficiency in applications to
the eyes of children, mentioned in Chapter XVIII,
must be resorted to.
Prognosis. — The individual attack of phlyctenular
disease is usually recovered from within two or three
weeks ; but subsequent attacks are extremely probable.
DISEASES OF THE CONJUNCTIVA. 265
Permanent damage always depends on the lesions of the
cornea.
Pterygium. — Pterygium is an extension of conjuncti-
val and subconjunctival tissue upon the cornea, triangu-
lar in shape, with the apex toward the center of the
cornea, and the base at the corneal margin, usually
toward the nasal side. Its appearance and usual situa-
tion are shown in Fig. 88.
FIG. 88.— Fterygium extending over the margin of the pupil.
Symptoms and Course. — Pterygium sometimes fol-
lows corneal ulcers. It also follows traumatism, and
probably arises from the presence of minute foreign
bodies, and chronic irritations without previous loss of
corneal tissue. In some way it seems to be largely in-
fluenced by climatic or local conditions, being much more
common in some places than in others. It is slowly
progressive, often for a long time ; but finally it becomes
stationary usually before it has encroached much upon
the area of the pupil. The conjunctiva covering it is
generally quite vascular and supported by a thick mass of
subconjunctival tissue, and this vascularity and thicken-
ing extend upon the sclera to the region of the caruncle.
It is probable that the thick developing mass of
connective tissue underneath it is a factor in the
drawing forward of the conjunctiva upon the cornea.
The vascularity and prominence of the pterygium vary
from time to time, being greatest during the period of
growth and often much diminished at later stages when
the growth seems to undergo partial atrophy. It is
loosely connected with the cornea, which, after its re-
moval, may be found normal except for the absence of
the epithelium and a slight disturbance and haziness of
266 PTERYGIUM.
its superfical layers ; the portion overlying the sclera is,
however, pretty firmly connected with it. It may occur
in early adult life, but is more common after middle age.
Pterygium is not painful, and so long as it does not
approach the region of the pupil, is only unpleasant
because of its appearance. If it encroaches upon the
pupil, sight is impaired ; and often before the growth
reaches the pupillary margin, an area of astigmatism
which advances before it, may impair vision, particularly
when the pupil is somewhat dilated. When very exten-
sive it may cause limitation of the movements of the eye-
ball and diplopia in the peripheral portions of the field
of fixation.
Diagnosis. — Ptergyium is to be distinguished from
superficial vascular keratitis by its appearance of lying
upon the corneaf having a margin distinctly elevated
above the corneal surface. It differs from dermoid of
the corneal margin in its greater vascularity, in the dis-
tribution of its vessels, and in its triangular shape as
contrasted with the rounded or ovoid form of the der-
moid. From pinguecula it differs in extending on the
cornea, which pinguecula never does (see Fig. 89).
Treatment.— If small and not progressive, removal is
not to be urged. During periods of excessive hyperemia,
the treatment may be that of a mild subacute conjuncti-
vitis. If progressive, and particularly if already ap-
proaching the pupillary margin, it should be removed.
This may be done by excision or transplantation.
Ligation, formally practiced, is not to be advised. The
advantage of transplantation is that, should the pterygium
again develop, requiring a second operation, the parts are
left in a more favorable condition for it. After excisions,
the loss of substance makes a second operation more
difficult, and more liable to cause impairment of the ocular
movements. For a very large pterygium, the most
effective method is to excise it and by an epithelial skin-
graft, or, better, a graft from the mucous membrane of the
lip, to cover the denuded portion of the sclera. The after-
treatment includes regular cleansing of the conjunctiva
DISEASES OF THE CONJUNCTIVA. 267
and the removal of the sutures, usually on the second
or third day. There is at first some swelling, but this
rapidly subsides. Small ptcrygia may be checked by
electrolysis, or the apex of the growth may be destroyed
by the galvanic or actual cautery.
Prognosis. — In a large proportion of cases pterygium,
if left to itself, never interferes seriously with the vision,
and operation is only of benefit in that it removes an
unsightly deformity. The rate of development or its
ultimate size cannot be surely predicted. The security
from recurrence depends much on the completeness of the
removal of the mass of connective tissue overlying the
sclera.
Pinguecula is a yellowish elevation of the conjunc-
tiva to the nasal side of the cornea, caused by an accumu-
lation of connective tissue and fat. It is shown in Fig.
89. When slightly inflamed, it may become prominent,
FIG. 89.— Pinguecula with large conjunctival vessels to the nasal side of the
cornea.
and cause disfigurement. It may develop into pterygium,
but usually it requires no treatment.
Pemphigus, in very rare cases, affects the conjunc-
tiva, isolated spots become affected, quickly lose their
epithelium, and undergo shrinking ; then other portions
of the membrane undergo the same changes until the
conjunctival sac is obliterated, the sight lost, and the lids
bound down closely to the globe. The disease occurs in
cachectic patients, who suffer from pemphigus affecting the
skin. Hygienic measures and internal remedies, especially
arsenic, are chiefly to be relied on. Locally, soothing
collyria may be used, and if the disease is once thoroughly
checked, skin-grafting into the conjunctival sac may be
resorted to.
268 CHRONIC DISORDERS.
Xerosis, or essential shrinking of the conjunctiva, has
been reported as occurring independently of pemphigus,
and occasionally as the final stage of that disease. The
cornea participates in the process, becomes dry and opaque,
and sight is lost.
Tuberculosis and I/upus of the Conjunctiva.—
Tubercular disease of the conjunctiva is rare, yet occa-
sionally cases occur. The course of the affection is very
chronic, and its general characters resemble those of
trachoma ; but it lacks the characteristic trachoma-gran-
ules, is less liable to involve the cornea, and is more regu-
lar in its course. The palpebral conjunctiva is chiefly
affected, and the lids appear swollen and firm to touch.
The infiltration as seen from the conjunctival surface,
while nodular, is red or yellowish-gray, and does not
resemble the sago-brains of trachoma. The surface often
becomes ulcerated, which is not the case with trachoma ;
and the lymphatic glands in front of the ear are apt to
be affected early.
Tubercle bacilli may be found in the secretion, but they
are few in number and may escape detection. Inocula-
tion of the diseased tissue into the anterior chamber of
the rabbit is a more reliable test. In most cases there is
evidence of tubercular disease in other parts of the body.
Treatment. — Locally, soothing applications and mild
antiseptics may be used, while the general treatment of
tuberculosis, including diet, regimen, and climatic influen-
ces, should be carefully carried out. Specific treatment
by injections of tuberculin may be resorted to. If, in
spite of these measures, the conjunctiva! lesions remain
unimproved, the affected tissue may be excised or cauter-
ized with carbolic acid, and dressed with iodoform.
Syphilis of the conjunctiva may occur at any
stage of the disease. The primary sore occurs most often
near the inner cauthus, or in the lower cul-de-sac. It
presents an ulcer with a hard base and glandular involve-
ment, lasts several weeks, and is comparatively painless.
In connection with skin-eruptions there may be a chronic
catarrhal conjunctivitis not influenced by local treatment
DISEASES OF THE CONJUNCTIVA. 269
or the removal of ordinary causes ; but curable by anti-
syphilitic treatment. Gumma is very rare ; but chronic
ulcer with great infiltration sometimes occurs in late
syphilis, and may be mistaken for cancer.
Amyloid degeneration of the conjunctiva is a rare
condition, characterized by the deposits of amyloid
material in the conjunctiva and lids. It is usually asso-
ciated with trachoma, but may occur independently. The
lids are thickened and rigid, the exudate being yellow in
color and occurring in larger masses than the trachoma-
granules, being continuous beneath the whole surface.
There is usually a history of previous disease, and absence
of the discharge and symptoms of acute inflammation,
which mark the progress of trachoma.
Symblepharon. — If in any way the conjunctiva is
destroyed on both the eyeball and the inner surface of
the lids, especially if such destruction involves the retro-
tarsal fold, the resulting cicatrix is liable to bind the lid
to the eyeball (see Fig. 90). This most frequently occurs
FIG. 90.— Symblepharon.
after burning of the conjunctiva with hot metal, lime, or
other caustics, the lower part of the conjunctiva being
usually affected. Sometimes the adhesion extends onto
the cornea, and may even cover the whole of it, prevent-
ing useful vision. Even when this does not occur, the limit-
ation of the movement of the eyeball may cause annoying
270 SYMBLEPHARON.
diplopia. The connection between the eyeball and the
lids is brought out most strongly by drawing the lid away
from the globe, when it is rotated away from the adhesion.
Such adhesions continue to contract and become more
annoying, often for many months, and the prognosis with
reference to them should be guarded.
Treatment. — Much ingenuity has been expended to
prevent the formation of such adhesions between the lids
and eyeball, by repeatedly breaking them up, or con-
tinuously wearing some form of metal shield. But little
ultimate benefit has resulted from such measures. Where
the connecting bridge of the conjunctiva is entirely
isolated, so that a probe can be passed beneath it (cmtcrior
symblepharoii), the division of the bridge gives complete
relief. If the fold extends to the conjunctival cul-de-sac
(posterior symblejlharon), but is comparatively narrow, it
may be possible to make a permanent opening behind it,
by wearing for six weeks or longer a piece of lead wire
passed through its base ; or it may be divided near its base,
and the conjunctiva from opposite sides brought together,
making an isolated bridge of the adhesion, which can
subsequently be divided. In a majority of cases requir-
ing operation such methods are inapplicable, and the best
result is to be obtained by freely dissecting the joining
fold away from the eyeball, allowing what there is of it
to go as epithelial covering for the lid, and covering the
denuded area of the globe by mucous- or skin-grafts. The
mere division of a symblepharon gives only temporary
benefit.
Edema has been referred to in connection with con-
junctival inflammation. It may, however, occur apart
from this, in cases of paralysis of the ocular muscles, as
an effect of certain drugs, particularly potassium iodid
and quinia, or as a variety of so-called angioneurotic
edema. Emphysema of the subconjunctival tissue
may occur from injury in the nose.
IJcchymosis. — Small hemorrhages into the conjunc-
tiva and deeper tissues mark the course of all severe
conjunctival inflammation, and especially that of acute
DISEASES OF THE CONJUNCTIVA. 271
contagious conjunctivitis. More extensive extravasations
of blood occur by the rupture of blood-vessels during
coughing, vomiting, etc. in purpuric conditions, from
general vascular degeneration sometimes preceding hem-
orrhage into the brain or other vital organ, and even
without any discoverable cause. Such extravasations
require no treatment, undergoing complete absorption,
without causing unpleasant symptoms other than the
disfigurement.
Tumors. — Benign tumors occasionally occur in the
conjunctiva. Clear cysts form especially in the lower
cul-de-sac. Angiomas involve the lids, and are con-
sidered in that connection. Dermoids usually involve
the corneal margin. Fibromas occur as small polypoid
growths, and osteoma has- been met with. Papillo-
mas grow in masses with a structure and surface resem-
bling cauliflower. They start usually from near the inner
canthus, but may extend so as to hide the cornea. They
recur unless very completely removed. Lipoma is seen
on the outer portion of the eyeball. Cysticercus occurs
rarely. On the West Coast of Africa the "eye-worm,"
//'/"/•/a, is acquired. It may be seen at times rapidly
moving under the conjunctiva. These tumors and para-
sites are to be treated by removal.
Epithelioma may start from the conjunctival margin of
the cornea ; in this situation it is sometimes pigmented.
Sarcoma arises from exposed portions of the conjunctiva
and is usually pigmented. Such tumors of the conjunc-
tiva usually develop very slowly. Their early removal
without sacrificing the eyeball may be tried, but if there
be doubt as to the completeness of such removal, extirpa-
tion of the eye, with the growth, is necessary.
Concretions in the Conjunctiva. — On everting
the lids one may often detect one or more yellowish
masses, the size of a pin-head, lying in the conjunctiva.
These are accumulations, in small divisions of the Meibo-
mian glands, or in the other glands of the mucous mem-
brane. They are at first of cheesy consistence, and may
remain a long time without making any disturbance,
272 CONCRETIONS IN THE CONJUNCTIVA.
although patients not rarely discover them, and ascribe
to their presence symptoms due to other causes. They
may, however, undergo calcareous changes ; and, by
thinning of the membrane over them, come to act very
much as foreign bodies in the conjunctiva! sac, causing
irritation, redness and discomfort. If this occurs, eacli
offending mass should be removed. It is readily turned
out of its bed with the point of a needle.
Burns of the conjunctiva may occur, from hot
steam, ashes, powder, other explosives, or drops of molten
metal. Similar injuries may be caused by contact with
some caustic, such as strong mineral acids and alkalies,
and especially lime. Whether the injury be by heat or a
chemical caustic, the affected tissue will be found rather
pale and opaque^ and edema of the adjoining tissues
quickly develops. The danger of such injuries lies in
the involvement of the cornea and in the liability of their
causing symblepharon. The resulting inflammation,
unless very severe, is usually limited to the immediate
seat of the injury, which is the conjunctiva of the eyeball,
except when molten metal or caustic has run into the
lower cul-de-sac, involving also the palpebral portion of
the membrane. A like distribution of the redness and
swelling characterizes the resulting conjunctivitis.
Occasionally a sharp attack of conjunctivitis is caused
by sunburn. The hyporemia is most severe in the por-
tion of the conjunctiva exposed to the sun's rays; but
there may be general swelling of the membrane, and
acute burning and smarting.
Treatment. — As promptly as possible any foreign par-
ticle remaining at the seat of injury should be removed,
and a chemical caustic thoroughly neutralized. The
stronger acids may be removed and neutralized by thor-
oughly washing with a solution of borax, and the alkalies
by washing with milk or sweet oil. The action of lime
may be checked by dropping sweet oil or a solution of
cane sugar into the eye. Particles of lime become firmly
united to the eschars they cause, but their removal should
be accomplished. After this the eye may be treated with
DISEASES OF THE CONJUNCTIVA. 273
borax and boric acid solution, to thoroughly cleanse it,
and a drop of liquid petrolatum instilled to protect the
exposed nerve-endings. Eschars should not be disturbed
any more than is necessary for removing foreign particles,
or neutralizing the caustic causing them.
Other injuries and foreign bodies are considered
in Chapter XVII.
Discoloration of the ocular conjunctiva by pigment
deposits is common in the colored race ; and occasionally
occurs in the white. A more general and uniform brown-
ish discoloration is caused by long continued applications
of silver nitrate. In Addison's disease and in various
forms of anemia, the conjunctiva is transparent, and the
sclera seen through it, pearly white. This is to a consid-
erable extent normal in young children, the conjunctiva
and subconjunctival tissue becoming thickened, more
vascular and yellower with age.
Diseases of the Caruncle. — Inflammation of the
caruncle occurs with conjunctivitis. It is marked by
redness and swelling. It is particularly noticeable in
conjunctivitis from eye-strain, when the other evidences
of conjunctivitis may be slight and easily overlooked.
Occasionally the caruncle is the seat of abscess. Chronic
non-inflammatory enlargement is called encanthis. Occa-
sionally numerous short hairs spring from the caruncle.
They may be so directed as to cause redness and irritation
of other parts.
CHAPTER X.
DISEASES OF THE COENEA AND SCLERA.
General Conditions Regarding the Cornea. —
The cornea is composed chiefly of a tissue closely allied
to white connective tissue, is normally devoid of blood-
vessels, and is covered with a layer of conjunctival epi-
thelium. With the latter point may be associated its
liability to involvement in conjunctival disease. Its lack
18
274 DISEASES OF THE CORNEA.
of vessels causes the location of hyperemia connected
with morbid processes affecting it, to be in the zone
immediately surrounding it, where ramify the vessels
from which its nutriment is drawn. This separation of
the tissue from its base of supplies causes its particular
liability to undergo ulceration and to slough. Conical
inflammations are liable to run the chronic course that
inflammations do in white fibrous tissues in other parts
of the body. Its transparency depends upon a delicate
balance of nutritive processes, likely to be disturbed by
any departure from the normal ; and rarely entirely
regained when any considerable portion of its tissue is
replaced by the new-formed connective tissue of a scar.
Many of the inflammations in it are characterized by loss
of substance giving rise to corneal ulcers. Where this
does not occur, or after the replacement of tissue lost, the
prominent symptom is the opacity.
Finally the corneal tissue is compelled to sustain the
outward pressure of the intra-ocular fluids, and when
softened by disease it gives way before this pressure,
causing changes of shape and permanent disturbances of
its nutrition. And whenever corneal inflammation lasts
for any considerable time there is a tendency to extension
of the blood-vessels upon and into the corneal tissue.
These vessels continue to develop until the inflammation
has passed its height, and the process of repair is well
started ; then they diminish in size and number, and may
entirely disappear.
The special conditions affecting the cornea cause pecu-
liarities in the symptomatology and therapeutics of corneal
inflammations that must be strongly emphasized, lest
they be overlooked or neglected. That the absence of
vessels in the cornea causes the redness of keratitis to
appear as a pericorneal zone, has long been recognized ;
but attention has only recently been drawn to the signifi-
cance of the corresponding ring exudate ; so-called y//u/-
abscess of the cornea. An acute, severe injury to the cor-
nea, whether by infected wound or the toxins of virulent
bacteria otherwise introduced, causes an abundant immi-
gration of leucocytes. These, pressing toward the corneal
DISEASES OF THE CORNEA. 275
center, leave the cornea! margin comparatively clear, while
necrosis or irreparable damage to the central portion of the
cornea checks or arrests their progress, massing them in a
ring of exudate. This ring may be incomplete in some par-
ticular direction, or other influences may change its shape,
so that the front of the cell exudate may appear as an irreg-
ular or a straight line ; or as two lines meeting at an angle.
FIG. 90 a.— Ring abscess of the cornea.
The temperature of the cornea, at least while the eye is
open, is decidedly lower than the general body tempera-
ture. To this lower temperature, unfavorable to the
development of many of the pathogenic bacteria, especi-
ally the gonococcus, may be ascribed apart of the immu-
nity of the cornea from infection. The advantage of
such immunity is wholly lost when the eye is kept closed
under a warm bandage. Indeed, it is probably only
maintained by iced applications to the closed lids so long
as the lids are not materially thickened by exudate. It
is best preserved when the eye is kept open most of the
time, exposed to comparatively cool atmosphere. This
therapeutic advantage is given up whenever we use a
bandage or fix a dressing upon the eye.
The mechanical cleansing of the cornea by the margin
of the upper lid during the act of winking is wonder-
fully complete. Upon the smooth cornea with normal
nictitation, it is almost impossible for germs to find lodg-
ment in injurious amounts. Conjunctival swelling at the
limbus, or any abrasion of the corneal surface, permits
bacterial colonies to gain a foothold. Hence, avoidance
of the slightest mechanical injury to the corneal margin';
or its exposure by incision, reducing chemosis, are thera-
peutic indications of great practical importance. The
cleansing influence of normal nictitation is also lost by the
use of fixed dressings.
276 CORNEA L ULCERS.
CORNEAL ULCERS.
Simple Ulcer of the Cornea (Non-suppurating
Ulcer, Ulcerous Keratitis). — This condition consists
essentially in loss of a portion of the corneal epithe-
lium, and of the true corneal tissue beneath. It may arise
from traumatisrn, either external or that due to a rough
or deformed lid; or from a local inflammatory process,
attended with disintegration of tissue, as in phlyctenular
keratitis, or herpes of the cornea ; or as a complication
in acute conjunctivitis.
Symptoms and Course. — The loss of corneal sub-
stance is to be detected by the irregularity or break that
it causes in the reflection from the cornea of a window
or lamp-flame when this is reflected from the part in-
volved. It is colhmonly attended with pain of a burn-
ing, smarting or aching character, dread of exposure to
light and air, and excessive lacrimation.
An ulcer may properly be classed as simple when not
surrounded by markedly infiltrated and disintegrated
tissue, when it does not tend to materially extend after
its first formation, and is not complicated by perforation
or other accident. In its earliest stage its surface lacks
the polish of the normal cornea. But as soon as the pro-
cess of repair is fairly started the bottom of the ulcer
appears glazed over, giving as bright a reflection as does
the cornea around it, although its surface may be quite
noticeably depressed.
During the process of repair, the excavation fills up
until the surface of the ulcer becomes continuous with
that of the surrounding cornea. This is accomplished by
the formation of new tissue beneath the epithelial layer,
which new tissue is at first not perfectly transparent, but
rather gray in color ; so that the opacity attending such
an ulcer tends to increase throughout the period of heal-
ing, and is most noticeable several days, or sometimes
weeks, after pain and other evidences of inflammation
have disappeared.
The existence of an ulcer is quickly followed by
DISEASES OF THE CORNEA. 277
hyperemia of the nutritive vessels of the cornea, causing
a red or pink pericorneal zone. If the ulcer be situ-
ated near the center of the cornea this zone will be almost
equally pronounced all around the corneal margin. If
the ulcer be close to the corneal margin, the portion
of the pericorneal zone adjoining it will be chiefly, or
alone reddened ; and as the ulcer heals, the redness will
disappear last in this locality. Pain is usually consider-
able, and in some forms, especially where there is a broad
shallow excavation as by an infant's finger nail, or in the
ulcers that occur with chronic conjunctivitis in old people,
pain may be very severe. It is generally accompanied
by photophobia and excessive lacrimation.
Diagnosis. — The careful inspection of the reflex from
every part of the corneal surface will usually reveal the
loss of substance. If there is difficulty about discovering
it in this way, a drop of a solution of fluorescin will stain
the cornea green over the whole ulcerated surface reveal-
ing exactly its extent. It is sometimes difficult to dis-
tinguish an old opacity of the cornea from one due to
recent infiltration. On this account the inspection should
be made by daylight, or white artificial light, to recog-
nize the true color of the opacity.
Treatment. — If a corneal ulcer be due to traumatism,
any foreign particles remaining in it should be removed.
The tendency to recover is strong, and, beyond cleansing,
little active treatment is required. Still every ulcer,
however simple it may appear, is in danger of becoming
complicated by infection, and of extending so as to cause
perforation of the cornea, and, therefore, should be closely
watched. To guard against infection, the eye should be
cleansed with an unirritating solution, such as one of
boric acid or sodium chlorid, and kept closed between
the times of making applications to it, by a very light
dressing.
A mydriatic, such as atropin or duboisin, should be in-
stilled two or three times a day if there is decided redness
and irritation. Pain if not completely relieved by the
mydriatic, may be met by applications of heat, either
278 SIMPLE ULCER.
bathing with hot water, or the more continued applica-
tion of dry heat. Often the proper treatment of the
condition, either constitutional or local, which causes the
ulcer,, will be more important than the treatment of the
ulcer itself. Rest and a tonic treatment are usually in-
dicated.
Suppurating Ulcer (Per/orating Ulcer, Infecting or
Sloughing Ulcer, Ring Ulcer, Creeping Ulcer, or <sVv-
piginous Ulcer). — In this section are considered lesions
of varied character and due to many distinct causes, but
all characterized by a tendency of the ulcer to extend by
the disintegration of neighboring tissue. The direction
in which such extension occurs depends somewhat on the
cause of the lesion and has given rise to classifications
into varieties according to the form assumed. But while
these different vatieties vary somewhat in their clinical
aspects, in their essential dangers and treatment, they are
largely similar. For one who has large clinical exper-
ience and fair acquaintance with the subject, each of the
terms at the head of this section may serve to present a
distinct clinical picture. But for the student or practi-
tioner of moderate experience in dealing with corneal
ulcers, the essential facts will be best grasped by a
general description of those features which all varie-
ties have in common, with brief reference to specific
differences.
Symptoms, Varieties, and Course. — Suppurating
ulcer may start from an injury, from an apparently simple
ulcer, from the opening of a corneal abscess, or from the
sloughing of injured or severely infiltrated tissue. It
presents the symptoms of simple ulcer, but often of greater
severity and more rapid development. The floor of the
ulcer (when wiped dry) is devoid of luster, and is infil-
trated. The tissue at the margins is also clouded or
opaque with infiltration. The infiltration may be gray
or distinctly yellow, the latter color indicating a stronger
tendency to pus formation and rapid breaking down of
tissue.
The direction in which the infiltration is most marked
DISEASES OF THE CORNEA. 279
is that toward which the ulcer is most likely to extend.
If unchecked, the infiltration and disintegration of tissue
may rapidly involve large parts of the cornea (sloughing
ulcer), may extend to deeper layers of the cornea, leading
to perforation (perforating ulcer) ; may extend along the
conical margin until it forms a complete girdle around
the cornea (ring ulcer). It may extend rapidly by an
opaque yellow margin, first in one direction, then in a
slightly different direction, or even in an opposite direc-
tion, by a breaking down of the corneal tissue on one
side of it, usually with some undermining of the surface,
but without much tendency to penetrate the deeper
layers and perforate the cornea (serpent, or creeping
ulcer). So long as the ulcer has an opaque, sharply ex-
cavated, or undermined margin, and the adjoining tissue
remains devoid of vessels, the process is extending.
When the tissue adjoining the ulcer is found clear, or has
become distinctly vascular, the extension of the «lcer is
checked. When the floor of the ulcer (after wiping it
with absorbent cotton) is found smooth and reflecting like
the surface of the cornea, the process of repair is fairly
begun.
Perforation is the great danger of the corneal ulcer,
being followed by the most disastrous effects. No corneal
ulcer can be regarded as free from this danger so long as
it is extending or is opposed by inadequate power of
repair. The thickness of the normal cornea is usually
about 1 millimeter, but a cornea previously diseased, or
even a normal cornea, may be much thinner than this, so
that perforation may occur when not expected. On the
other hand, some forms of corneal ulcer have swollen
margins, so that with a depth as great as the normal
thickness of the cornea, no perforation may occur.
The deepest layers of the cornea, and particularly the
membrane of Descemet, usually resist the process of dis-
integration longer than the more superficial portions, so
that after the ulcer has reached them its further progress
may be checked. When, however, the floor of the ulcer
is wide, the thin layer of tissue forming it is unable to
280
. SUPPURATING ULCER.
resist the intra-ocular tension, and may be found bulg-
ing into the ulcer, concealing its real depth, until the
thinned tissue gives way. In a few cases the disintegra-
tion extends quickly to the deeper layers of the cornea,
and the whole thickness of the membrane separates in a
single slough. After the cornea has been perforated the
ulcer may continue to extend until the cornea has been
destroyed. In other cases the process of repair now gains
the advantage over the process of disintegration, and no
further extension of the disease occurs.
With perforation the contents of the anterior chamber
escape, and the iris and lens are pushed forward against
the cornea. If the perforation be
in front of it, the iris commonly
becomes adherent to the margin,
and the aqueous humor, accumu-
Jating behind it, pushes it forward
into the opening. This condition
is shown in Fig. 91. In this situ-
ation its surface quickly becomes
coated with plastic exudate, which
undergoes organization, and the
mass of new tissue, with the altered
iris, forms the scar-tissue that re-
places the part destroyed in the
formation of the ulcer. (See Cor-
neal Opacities.)
With the escape of the con-
tents of the anterior chamber the
pupil strongly contracts, so that the iris is drawn in
front of the perforation unless it be very small and
quite central. In that case the lens may be pushed for-
ward and close the opening. Even when the perforation
is in front of the iris, the lens-surface may come in con-
tact with the cornea. It then becomes the seat of plastic
exudate, and the epithelium of the capsule undergoes pro-
liferation, at least, in young patients. The exudate closing
the opening in the cornea, allows the reaccumulation of
the aqueous humor, which pushes the lens back from the
FIG. 91.— Perforating ulcer
of the cornea with incarce-
ration of the iris and com-
mencing repair.
DISEASES OF THE CORNEA. 281
cornea! opening, putting the exudate connecting the lens
and cornea upon the stretch, and breaking it and re-estab-
lishing the anterior chamber. The drag upon the lens-
capsule in this process, with the influence of the exudate
remaining upon it, tends to establish a small opacity —
anterior polar cataract (see Chap. XIV).
Causes. — To the causes sufficient to produce simple
ulcer of the cornea, are always added for the production
of suppurating ulcer, local infection and insufficient re-
sisting power on the part of the tissue. The infective
agent is usually one of the pyogenic organisms, which
may be derived from the discharge of a purulent conjunc-
tivitis, or the regurgitation from a chronically inflamed
lacrimal sac. Or it may be the pneumococcus which
Holden has connected with serpent ulcer, tending to
extend between the corneal layers ; or the diplobacillus,
or the diphtheria bacillus, or one of these with the pus
cocci.
The deficient resisting power may be caused by pres-
sure of severe chemosis, or greatly swollen lids upon the
pericorneal vessels that furnish the nutritive supply of the
cornea. It may be due to impaired innervation, as in
paralysis of the fifth nerve, or with herpes zoster. Or it
may be due to some specific poison acting upon the tissue
through the general circulation, as in small-pox, where
the cornea is liable to become involved ; or to an impaired
or debased nutritive supply from general disorders of the
circulation, or wasting disease. It may follow unnatural
exposure of the cornea, and inability of the lids and tears
to keep it properly cleansed, as by cicatricial destruction
of the lids, paralysis of the orbicularis muscle, or pushing
forward of the eyeball in exophthalmic goiter, or orbital
tumor.
Diagnosis. — Besides the points mentioned as to the
diagnosis of simple ulcer, in every case of corneal sup-
puration it must be carefully determined which of the
above conditions share in causing the lesion ; and at each
visit the surgeon must try to ascertain by careful exami-
nation whether the infiltration that precedes loss of sub-
282 SUPPURATING ULCER.
stance is still extending. The exact organisms of infec-
tion can only be determined by careful microscopic and
culture examinations of the scrapings obtained from the
surface of the ulcer.
Treatment. — In the earlier stages the important thing
is to check the progress of the ulcer. This will be
effected by combating the causes, and by disinfection of
the ulcer itself. Thus, in a case of purulent conjunc-
tivitis, the treatment of the conjunctivitis must be pushed
energetically. Where the infection comes from regurgi-
tation from the lacrimal sac, the sac must have thorough
antiseptic treatment. In so far as the breaking down of
the corneal tissue is due to general impairment of nutri-
tion, tonics and stimulants must be resorted to. If the
nicer is of traumatic origin, it should be thoroughly freed
from any retainea foreign particles.
In carrying out these measures, however, care must be
taken not to do injury to the cornea itself. Thus, in
making applications of silver nitrate to the conjunctiva
in a gonorrhea! ophthalmia, care must be taken not to
allow the solution to come in contact with the cornea.
For the same reason the use of cold is contraindicated,
and hot applications that will quicken .corneal nutrition
are to be favored.
The early treatment of the ulcer itself is to disinfect it,
and to prevent reinfection. Many ulcers do better under
a light protective bandage that keeps the eye closed and
excludes foreign matter. Particles of dust lodging on
the normal cornea are promptly wiped away by the mar-
gin of the lid and carried off in the tears. But when
there is loss of substance, the lid-margin cannot remove
from the interior of the nicer the particles which may
lodge upon it, and which, therefore, remain to increase
irritation and renew infection. The chief means of dis-
infection is the mechanical removal of disintegrating
tissue by curetting, and the destruction of it by the actual
cautery. For ulcers that are spreading at all rapidly, the
infiltration extending beyond them into neighboring tis-
sues, caustics, like silver nitrate, or strong solutions of
DISEASES OF THE CORNEA. 283
mercuric chloric!, have not sufficient penetrating power
to be efficient.
The most generally applicable treatment is thorough
curetting or scraping. This may be done with a spud for
the removal of foreign bodies or other blunt instrument.
(See Chapter XIX.)
This operation not only removes most of the infected
and infective material, but it also quickens the flow of
lymph in the direction of the ulcer, tending still further
to limit infection. It must be repeated as often as the
area of infiltration is found to be extending ; sometimes
within twelve hours, usually within a day, if repetition
be required at all.
Where the case can be carefully watched and the ulcer
efficiently scraped as often as is necessary, this mode of
treatment is usually efficient. When, however, the ulcer
is deep, the pressure necessary in curetting may cause the
rupture of the thinned cornea ; and where the patient
cannot be frequently examined, or where his control over
the eye is so poor that curetting cannot be thorough, the
actual cautery is distinctly superior.
For the cauterization of an ulcer, the corneal cautery,
a probe, or a steel knitting-needle may be heated to white
heat in an alcohol flame ; or the galvano-cautery may be
employed to touch and destroy all the infiltrated tissue
(see Chap. XIX). The eye may then remain closed for
several hours, unless conjunctival discharge needs to be
removed. The slough left by the cautery will in many
eases prevent the very early recognition of extension of
the disease. But if the application has been sufficiently
thorough, subsequent extension will generally not occur.
The application of the cautery is not in itself very pain-
ful, if care is taken not to hold the heated metal close to
the eye, but to touch the affected area and then withdraw
it ; and its application is usually followed by consider-
able relief from pain due to the ulcer.
The removal of softened tissue by a forcible jet of
water or some antiseptic solution, called hydraulic cu-
retting, has been highly recommended.
284 SUPPURATING ULCER.
Where other means fail to arrest the progress of the
ulcer, a powerful influence in that direction is brought
into play by paracentesis of the anterior chamber. This,
by relaxing the tissue of the cornea, causes a considerable
increase in the stream of lymph passing into that mem-
brane from its nutrient vessels, and allows the free escape
of this fluid externally, tending strongly to increase the
resisting power of the corneal tissue against the attack
of pyogenic organisms. The anterior chamber may be
opened by a broad needle or the point of a cataract-knife,
inserted near its lower margin, and then twisted in the
wound, sufficiently to allow the contents to drain away.
Or it may be opened by what is called the Saemisch
incision, which must extend through the cornea across
the ulcer from the sound tissue on one side to the sound
tissue on the othlr side.
Opening the anterior chamber may also be indicated
to relieve the tension of the cornea when the floor of a
deep ulcer seems to be on the point of bursting. The
operative incision is likely to heal without adhesions of
the iris, which would almost certainly occur should the
ulcer be allowed to perforate. It may be necessary to
reopen the incision on successive days with a probe to
secure the full benefit of this measure. After opening
the anterior chamber, as after perforation by the corneal
ulcer, the extension of the disease is generally checked
and recovery begins.
As a local application Chandler and Risley have
recently recommended a 10 per cent, ointment of cassa-
reep, both to relieve pain and favorably influence the
course of the disease. H. Derby has claimed the same
benefits from the use of holocain. A one per cent, solu-
tion of formaldehyd is sometimes beneficial ; but it cause-
pain which cocain will not prevent. Atropin, and some-
times eserin, are of value in relieving pain and improv-
ing the circulation.
In the way of general treatment, rest in bed is often
of great importance. Abundance of nutritious food is
usually indicated, and in a few cases alcoholic stimulants
DISEASES OF THE CORNEA. 285
prove of value. These must, however, be used with
great caution and their effect watched, for alcohol les-
sens the resisting power of the cornea! tissue to the
action of pyogenic bacteria. A remedy which seems to
increase the cornea! resistance is tincture of the chlorid
of iron, given in rather large doses. Quinin is also
valuable in tonic doses, due or two grains three times a
day. Pain may be relieved by morphin, acetanilid or
hot applications. The locat or systemic use of antipneu-
mococcic or .streptococcic serums has been credited with
good effects, but serum treatment cannot be relied on.
When the extension of the ulcer has been checked
and healing commenced, the local treatment should con-
sist in atropin, and cleanliness and rest of the parts, with
the continuance of such treatment of the conjunctiva as
may be necessary.
When perforation has occurred with prolapse of the
iris, if the ulcer be small and the cornea in favorable
condition, it may be well to excise promptly the pro-
truding iris, usually under general anesthesia. The
prolapse may first be seized with the forceps, and
somewhat dragged, first in one direction and then in
another, until it is probable that the adhesions between
the cornea and the iris are broken up. Then while the
iris is still on the stretch the prolapse is to be cut away,
as close to the margin of the ulcer as possible, either with
the scissors or by transfixing it with a cataract-knife and
shaving it off close to the cornea. If the operation has
been successful, the cut edges of the iris will be at once
retracted into the anterior chamber and away from the
margin of the corneal perforation. If the neighboring
cornea be much infiltrated, or if the prolapse be very
large, or of more' than one day's standing, it is better to
leave it alone. If later the cicatrix shows a decided
tendency to excessive bulging, healing may be hast-
ened and made more satisfactory by excision of the
prolapse (as described in Chap. XIX) at a later pe-
riod. The treatment of the results of corneal ulcera-
tions will be considered under opacities of the cornea.
286 CORNEAL ULCERS.
Special Forms of Corneal Ulcer. — In old people
with impaired nutrition, a form of simple nicer, usual Iv
situated near the margin of the cornea, associated with
conjunctivitis, and often chronic or stibacute, causes r/rcat
pain without marked hyperemia of the eye or other evi-
dences of inflammation. It shows little tendency to
extend, and little tendency to heal spontaneously ; but
under the proper treatment, the instillation of a weak
solution of eserin and bathing the eye twice daily, or
oftener, with very hot water, and in some eases with the
use of a protective dressing, relief from pain, and healing
are promptly secured.
Malarial ulcer is common in patients who have suf-
fered from malarial disease. It is marked by slight
tendency to extension, much pain, and complete resist-
ance to local treatment unless accompanied by the internal
use of quinin with or without iron and arsenic. The ulcer
is branching in form ; and the part of the cornea on which
it is situated is often quite insensitive to touch. The in-
filtration is moderate, and gray in color ; and the pericor-
neal redness commonly severe.
Herpetic ulcer, described by Homier, occurs with
herpes of the lids and other parts of the face, in connec-
tion with febrile diseases, especially of the air-passages,
as pharynigitis, bronchitis, pneumonia, etc. It begins with
small vesicles on the cornea, severe pain, photophobia and
lacrimation. The vesicles are very small, but may run
together and form linear ulcers of considerable size.
Healing depends on the general nutrition of the patient,
but is usually prompt. The treatment is that for simple
corneal ulcer.
Dendritic or mycotic ulcer is named from its branch-
ing form, or from its supposed dependence upon a special
micro-organism. It is attended with marked photopho-
bia, lacrimation, and the hyperemia of keratitis. It
should be treated by thorough scraping, or by touching
each part of it lightly with the galvano-cautery.
Bullous keratitis occurs when the nutrition of the eye
has been damaged by previous disease, especially in con-
DISEASES OP THE CORNEA. 287
nection with chronic irklocyclitis or glaucoma. It also
occurs after traumatisms causing extensive abrasions.
Blebs either small or large form on the surface of the
cornea, with pain, hyperemia, and other symptoms of
infiltration. The blebs rupture leaving abrasions or
deeper ulcers. They tend to recur again and again. The
treatment consists in atropin and hot applications locally,
with avoidance of irritants, and a general tonic treatment
including quinin and iron. And in case of traumatic
origin, careful protection of the eye during healing. It
may be necessary to enucleate the eye if blind, on account
of the repetition of the attacks.
Filamentous keratitis designates a group of cases in
which from a corneal ulcer or wound-surface minute
threads of tissue or fibrin are found hanging.
Keratomalacia is an extensive softening and sloughing
of the cornea, occurring in patients very poorly nourished,
as after acute or chronic wasting disease, and especially in
infants. The treatment must be addressed to the general
condition, and the eye guarded from irritants.
Neuropathic or neuroparalytic keratitis occurs after
disease of the ophthalmic branch of the fifth nerve,
or its nuclei. The affection seems to be partly trophic
and partly traumatic in character. Ulceration often
occurs, but is not extensive if the ulcer be guarded from
infection. Some opacity of the cornea usually accom-
panies it. This form of ulcer is to be recognized particu-
larly by testing the sensibility of the cornea, or finding
other evidence of disease of the nerve. It is to be treated
by closure of the eye under a protective bandage, the in-
stillation of atropin, or a weak solution of eserin, cleanli-
ness, and careful avoidance of irritants. Treatment must
usually be continued for several weeks or longer, until
the resisting power of the cornea becomes re-established.
After destruction of the Gasserian ganglion, this disease
may be prevented by keeping the eye closed and carefully
protected for several weeks.
Herpes zoster, occurring in the distribution of the
ophthalmic branch of the fifth nerve, and particularly if
288 NEUROPATHIC KERATITIS.
vesicles occur on the side of the nose, is liable to be
accompanied or followed by the involvement of the cor-
nea. In some cases a vesicle forms on the cornea, leading
to ulceration and subsequent opacity. In other cases the
corneal changes resemble those of neuropathic keratitis.
The deeper structures of the eye may be involved and
the sight entirely lost. In most cases sight is perma-
nently damaged by resulting opacity. The neuralgic
pain which attends the disease may last long after the
local disease has run its course.
Phlyctenular Keratitis (Scrofulous Ophthalmia,
Strumous Ophthalmia, Lymphatic Keratitis, Faseicular
Keratitis, Vascular Keratitis). — This disease is essentially
the same as phlyctenular conjunctivitis (see p. 261), phlyc-
tenules occurring on the cornea instead of at the limbus, or
upon other portions of the conjunctiva. The conjunctiva is
more or less involved in all cases, but the disease only
becomes obstinate, severely painful, and dangerous to
sight, when the cornea is affected. The causes are those
of phlyctenular conjunctivitis.
Symptoms and Course. — The first perceptible lesion
of the cornea is an elevation of the epithelium at some
point by an accumulation of a serous fluid beneath it.
This is the corneal phlyctenule. Michell has recently
found that it is essentially a lesion of reaction against
micro-organisms, especially the staphylococcus. The epi-
thelium covering it quickly gives way, the fluid escapes,
and a small approximately circular ulcer is left. This
occurrence is attended with pain, photophobia and exces-
sive lacrimation ; and there is hyperemia of the ocular
conjunctiva and of some portions, or all, of the pericor-
neal vessels. The photophobia is generally even more
marked than with phlyctenular conjunctivitis. Often
two or three or more phlyctenules occur together, or they
may follow each other in quick succession. Usually the
ulcer formed heals rapidly, leaving a slight nebula and
some irregularity of the corneal surface. But in more
severe cases, or after repeated attacks, the healing is slow,
superficial vessels extend from the limbus to the seat of
DISEASES OF THE CORNEA. 289
the ulcer, and continuing from ulcer to ulcer may form
a leash stretching to the center of the cornea, or beyond
it. The disease shows a strong tendency to relapse, and
with successive attacks, the restoration of the eye to nor-
mal during the intervals becomes less complete ; until it
remains continuously hyperemic, with a clouded and vas-
cular cornea.
Treatment. — The general lines of treatment indicated
for phlyctenular conjunctivitis, must be followed with
more care and constancy when the cornea becomes in-
volved ; and in addition special measures must be adopted
for the keratitis. The irritability of the eyes, and dread
of exposure to the light and air, cause the child to bury
its eyes in a handkerchief or a pillow, to avoid all ex-
posure of them. This is particularly unfortunate, since it
tends strongly to aggravate and continue the disease.
Indeed, if in any case free exposure of the eyes to light
and air can be maintained, the cure of the eyes, except as
to removal of opacities and irregular astigmatism, is not
usually difficult. The excessive irritability is best met
by instillation of a mydriatic, preferably atropin. A
powerful aid in this is the regular application of the
solution of tannin in glycerin to the inner surface of the
lids, once every two or three days, and the diffusion of
ointment of the yellow oxid of mercury, in the conjunc-
tiva! sac every night. In addition, dark glasses should
be worn to protect the eyes from the light, and to prevent
the constant application of a handkerchief to them, while
permitting the air to circulate about them.
The small fissures which form in the skin of the lids
near the outer canthus, should be touched from time to
time with a solution of silver nitrate, and the skin care-
fully dried and protected with some petroleum prepara-
tion. Where photophobia is very great the sudden plung-
ing of the face in ice-cold water has been practiced with
advantage ; but this is rarely necessary.
During the stage of ulceration, the treatment of simple
ulcer of the cornea must be followed, and care taken to
guard against infection. If the ulcer becomes chronic
19
290 PHLYCTENULAH KERATITIS.
and vessels extend out to it from the corneal margin, it
should be scraped or lightly touched with the actual
cautery. For the treatment of resulting opacities, see
Opacities of the Cornea.
Prognosis. — Phlyctenular keratitis rarely causes abso-
lute blindness ; but when neglected, it is responsible for
many cases of life-long impairment of vision. Promptly
treated, such impairment can almost always be prevented.
Abscess of the Cornea, Hypopyon and Onyx.—
When the process of suppuration at first aifects a limited
portion of the deeper tissue of the cornea, abscess results.
It may follow traumatism, or be secondary to suppura-
tion in other parts of the eye. Its symptoms are, in the
main, those of suppurating ulcer of the cornea, which it
tends to become by the breaking down of the more super-
ficial layers of the cornea. It is usually attended with,
severe pericorneal hyperemia and great pain. In some
cases the conjunctiva becomes chemotic and the lids ede-
matous. The symptoms increase in severity with the
extension of the abscess until it opens, usually upon the
corneal surface ; after which it runs the course of a sup-
purating ulcer. It must be distinguished from a plastic
deposit or a cicatrix in the cornea chiefly by its color
and the history of the case.
Hypopyon is the accumulation of pus in the anterior
chamber. It may depend upon abscess or suppurating
ulcer of the cornea ; or upon suppurative disease of
FIG. 92.— Cornea] ulcer on the upper temporal quadrant, with hypopyon occu-
pying the lower one-third of the anterior chamber.
the iris or deeper portions of the eye. It is illus-
trated in Fig. 92. A considerable amount of pus
may pass through the anterior chamber without any
visible accumulation. Only when the amount poured into
DISEASES OF THE CORNEA. 291
the aqueous humor is too great to escape promptly, or
when the consistence of the material is such as to prevent
its escape, does hyopyon develop. Because some pus is
always passing from the chamber, and the hypopyon
represents only a certain residue or excess, it may vary
greatly in amount, being at one time barely perceptible,
and a few hours later tilling a large portion of the cham-
ber. It appears as a yellowish mass behind the cornea,
with a curved lower border corresponding to that of the
anterior chamber and a horizontal upper margin. Often
it is promptly displaced and its upper margin changed by
a change in the position of the eye. But if it contains a
considerable proportion of plastic material its form may
alter quite slowly.
Onyx is an accumulation of pus in the cornea between
the layers of the true corneal tissue. It occurs at the
lower portion of the cornea, by gravitation of pus from
a suppurating ulcer or abscess. It is bounded above by
an approximately horizontal line, and is less likely than
hypopyon to change shape or position with movement of
the eyes.
Treatment. — Like other purulent accumulations, the
above should be treated by free evacuation and drainage.
When hypopyon is slight, if there be no other indications
for opening the anterior chamber, it may be left undis-
turbed. With onyx, if at all considerable in amount, it is
better to incise the cornea deeply enough to allow the escape
of the accumulation. The corneal tissue may not at first
be appreciably involved ; but to allow it to soak in the
purulent accumulation, might convert it into an ab-
scess. Corneal abscess should always be promptly and
freely opened. It never undergoes complete resolution ;
and usually it continues to extend until it secures a free
exit. Usually either a crucial incision should be made,
or the tissue of the cornea superficial to the abscess en-
tirely cut away, and the abscess-cavity thoroughly scraped.
Even if it is subsequently to be cauterized, it may be better
to first freely open it. After it has been opened, it should
be treated as any other suppurating ulcer.
292 CORNEAL INFLAMMATIONS.
NON=ULCERATIVE KERATITIS.
Interstitial Keratitis (Parenchymataiis, Syphilitic,
Strumous, or Diffuse Keratitis). — In many cases inflamma-
tion of the cornea shows no tendency to cause loss of
substance, or suppuration ; but goes on to the deposit of
new material causing opacity, with often the extension of
blood-vessels into the cornea. All such cases properly
belong under the head of Interstitial Keratitis. No
sharp line of distinction separates these from other forms
of keratitis. In superficial vascular keratitis, the vessels
and the exudation may often be seen to invade the true
corneal tissue. The invasion is even more common and
more marked in pannus. And corneal ulcerations occa-
sionally occur in the course of typical interstitial keratitis.
Causes. — Undft* interstitial keratitis are included cases
due to many causes. Keratitis attending herpes zoster,
or fifth-nerve paralysis may be largely of this character.
Arlt named as its most important variety lymphatic or
scrofulous keratitis. But Hutchinson's description of
interstitial keratitis due to hereditary syphilis, is so
definite and fits so many cases, that it is best taken as the
type of the disease, with which other varieties may be
compared. Even when clearly associated with hereditary
syphilis, the attack may be excited by acute illness,
rheumatism, eye-strain, exposure to local irritants, or
other unhealthy influences ; and relapses and recurrences
are commonly so caused. Interstitial keratitis may arise
late in the course of acquired syphilis.
Symptoms and Course. — The disease begins with
irritability of the eyes, photophobia, pericorneal redness,
and interference with vision ; which, at first very slight,
increase from day to day until they become intense. As
the symptoms increase in severity, from some part of the
corneal margin, most frequently above or below, a broad
mass of fine looped vessels begin to encroach on the
cornea. These are surrounded by opacity, and give the
affected region a peculiar yellowish-red or salmon color.
Examination with a magnifier demonstrates that the
DISEASES OF THE CORNEA. 293
opacity and vessels are in the depth of the cornea. At
the same time, the changes beneath it render the corneal
surface quite irregular.
The opacity of the cornea may increase until the iris
and pupil are quite hidden, and the patient practically
blind. Sometimes before this, and often after the cornea
has cleared up again, the iris may be seen to be bound
down by posterior synechise of greater or less extent.
In a few cases, deposits in the anterior chamber also cause
extensive anterior synechise, without there having been
any perforation of the cornea. Sometimes one eye is
affected before the other, or more severely affected than
the other; but usually both are involved. The cornea
may resemble ground glass, or the deposits in certain
parts may be completely opaque. Sometimes they are so
dense and yellow as to look like corneal abscess ; and
if attended by decided swelling, may properly be regarded
as gumma of the cornea.
After a time, which varies from a few weeks to many
months, the corneal opacity begins to grow less dense.
This is first noticed near the margin of the cornea, the
center remaining clouded longest. But at length the cen-
tral cloud gets thinner, and the corneal vessels diminish
in size and grow less numerous. Some of the vessels,
however, often remain and may be discovered with a
magnifier years afterward, or throughout life. Usually
the cornea becomes comparatively clear again, but almost
always shows some haziness by oblrque illumination,
and causes marked irregular astigmatism with correspond-
ing permanent impairment of vision. In many cases,
even when carefully treated throughout, the iris is left
bound down by synechise. Often, too, the ophthal-
moscope shows that the inflammation has involved other
parts of the uveal tract ; and patches of choriodal
atrophy, and pigment changes remain as permanent
records of the attack. Interstitial keratitis occurs chiefly
between the ages of five years and twenty. Its duration
is from a few weeks to two or three years ; and slow
clearing of the cornea may continue even longer.
294 INTERSTITIAL KERATITIS.
Varieties. — When not due to inherited syphilis, the
disease is apt to run a less uniform course, and periods
of improvement may alternate with exacerbations. The
cornea is often less vascular, the vessels do not run in
such characteristic loops, and the opacity is less likely to
be evenly distributed. When due to scrofula, there is
more apt to be ulceration.
In a few cases, a cloud of opacity is limited to a cer-
tain part of the cornea, usually the center, and but few
if any corneal vessels develop (circumscribed infiltration of
the cornea).
Occasionally, in connection with a focus of scleritis
situated near the corneal margin, a somewhat triangular
opacity will extend into the cornea, which to some extent
becomes permanent, and appears as an extension of the
solera. This process may be repeated at various parts of
the corneal margin. It is called sclcrosing keratitis. In rare
cases in old people, there sometimes occurs a yellowish
exudation at the margin of the cornea, with symptoms of
inflammation which later subside. The vessels of the
limbus extend in over it, the opacity becomes gray, and
closely resembles an arcus senilis, except that no clear
tissue separates it from the corneal margin. This is called
keratitis marginalis.
Diagnosis. — Interstitial keratitis is recognized by the
general distribution of the opacity in the cornea, its
depth, and the form and situation of the vessels. The
vessels are arranged in fine approximately parallel loops,
which start from the deeper portions of the corneal mar-
gin. This is illustrated in Fig. 93, in which A represents
the vessels in interstitial keratitis, B those of phlyctenu-
lar keratitis, and C those of pannus. In these latter
forms of vascular keratitis, the vessels start from con-
junctival vessels and increase in number and diminish in
size by branching off from main trunks.
The pericorneal redness is usually unmistakable at
the height of the attack, although there may be, in
addition, some conjunctiva! hyperemia. At an early
stage the diagnosis will be greatly aided by other evi-
DISEASES OF THE CORNEA. 295
dences of inherited syphilis, especially the sunken
bridge of the nose, scars about the angles of the
mouth, and the Hutchinson teeth. The characteristic
deformities of the teeth consist in the notching of the
central incisors, and the peg shape and deficient develop-
FIG. 93.— Vascular keratitis. Distribution of corneal vessels in the various
forms. A, Interstitial ; B, Phlyctenular or fascicular; C, Pannus
raent of the lateral incisors. These are shown in
Fig. 94.
These deformities are only exhibited by the permanent
teeth. The milk teeth are generally poor, decaying often
down to the gums before they are replaced. Any marked
deformity of the permanent incisors, especially if they
are small so that they do not fill the jaw, but stand
separately with gum showing between, may be due to
inherited syphilis. But as Harrison Allen pointed out,
considerable disturbances in the development of the
FIG. 94.— Hutchinson teeth.
teeth are also caused by the exanthemata of childhood,
occurring when the crown of the tooth is developing.
Some deformity of the teeth is present in half the cases
of interstitial keratitis. The history of still-births, or
repeated miscarriages before the birth of the patient, also
points strongly to inherited syphilis.
296 INTERSTITIAL KERATITIS.
After the keratitis has run its course, the existence of
synechise, or patches of choroidal atrophy and pigment-
changes, indicate the nature of the disease that has left
the cornea defective. The same evidences may raise a
strong probability of intra-uterine interstitial keratitis,
causing congenital opacity of the cornea.
Impaired hearing due to lesions of the internal ear
often coming on, or growing worse at the time of the
keratitis, also indicates syphilis.
Treatment. — The local treatment should include the
regular instillation of a solution of atropin, so long as
there continues any pericorneal redness ; and afterward
until the eyes cease to be unduly irritable. The strength
of the solution and the frequency of the instillations
should be sufficient to keep the pupil well dilated ; or if
this cannot be accomplished, as much atropin must be
instilled as can be used without causing serious general
symptoms of mydriatic intoxication. Atropin is to be
preferred to other strong mydriatics because its action is
more persistent, and it is less likely to cause general
symptoms.
The action of the atropin may be aided, and pain dimin-
ished by bathing the eyes, for three to five minutes before
each instillation of the drug, with very hot water. If
the hyperemia is very great, a decided beneficial influence
is exerted by abstracting an ounce or more of blood from
the temple with the artificial leech. This should be done
in the evening when it will have most influence in pro-
curing sleep. Dark glasses should be worn to lessen the
photophobia. Subconjunctival injections of mercuric
chlorid have been tried, but are of doubtful value. All
other local treatment should be avoided during the earlier
stages. Astringent and irritant applications are harmful.
When the hyperemia is almost gone, the ointment of
yellow oxid of mercury may be used to hasten the clear-
ing up of the opacity ; and other measures for the same
purpose will be indicated later (see p. 304).
The constitutional treatment is very important. This
should include a general tonic regimen, and for a case
DISEASES OF THE CORNEA. 297
caused by syphilis a long-continued course of mercury in
moderate doses. The child should have plenty of sleep ;
a carefully regulated nutritious diet, avoiding tea, coffee,
and sweets ; regular cold bathing ; and out-of-door life,
away from dust and smoke, if possible. Syrup of iodid
of iron, syrup of hydriodic acid, or tincture of the chlorid
of iron may be given. Cod-liver oil is sometimes very
valuable. The mercurial course may begin with calomel,
until the bowels are decidedly acted upon, and then be
changed to inunctions with a drachm of mercurial
ointment once daily. If the mouth becomes at all
affected, the mercury should be suspended, and potas-
sium iodid in moderate doses (5 grains) given until
the mouth is well. Then the mercury may be given
in smaller dose. After the inflammation has passed its
height, the mercurial may be given in small doses
internally with potassium iodid.
Prognosis. — Interstitial keratitis may last from a few
weeks to five years. Very few cases recover under two
months, and the majority are fairly over it within a year.
But no one can tell at the .outset how long the particular
case will continue. It is safe in the beginning to predict
that the sight will get worse ; and at the height of the
disease, one can surely promise that it will greatly im-
prove in the end. Very few, if any cases recover normal
vision ; but the final opacity of the cornea may be scarcely
distinguishable. Recurrences of the disease are rare ; but
they may occur years later, and generally leave the
patient with poorer vision than he had after the first
attack.
Punctate keratitis is a term that has been applied
to the small points of deposit which occupy a triangular
space on the posterior surface of the cornea in cyclitis
and iridocyclitis. But in typical cases it is uncertain if
the condition of the cornea has any connection with their
formation, or does more than furnish them a resting-
place. In some cases of interstitial keratitis, the opacity,
especially at a late stage of the disease, consists chiefly
298 PUNCTATE KERATITIS.
of points grouped in the lower portion of the cornea,
ki'fdtifix jtiiiictata sypkUUica, or pro/undo.
A form of inflammation closely allied to corneal herpes,
but with little tendency to the formation of ulcers has
been termed kcrafifix jninctata superficialis. It begins
with symptoms of acute catarrhs! conjunctivitis. But
several days later, minute gray dots are found scattered
irregularly over the corneal surface, being least numerous
near the margin.
Striate keratitis occurs after injuries to the cornea.
It is characterized by lines of rather faint gray opacity,
that appear within the first two days after the injury.
It is most frequently seen after cataract extraction,
when the lines are found perpendicular to the direction
of the corneal incision. It is not of serious significance,
being unattended Vith other evidences of conceal inflam-
mation, and ultimately disappearing in all cases, often
within a week. It probably depends on dilatation of
lymph-spaces from general disturbance of the cornea, as
in the delivery of a full-sized hard cataract.
Pannus (trackomatow kemtitis, superficial vascular
kc-rdtitix) is primarily a disease of the conjunctiva cover-
ing the cornea. But since the deeper layers of the cor-
nea become involved, and it is attended with all the
symptoms of keratitis, it is well to consider it here.
Causes and Varieties. — The vascular opacity some-
times left by prolonged phlyctenular keratitis has been
called pannus. But the application of the term is now
usually restricted to the condition arising in trachoma.
If the layer of hazy vascular tissue be thin it is pannus
tennis ; if it be thick and fleshy, pannus crassus.
Symptoms and Course. — Pannus does not arise in
the course of trachoma, until that disease is well estab-
lished, causing marked roughening of the inner surface
of the lids. It occurs chiefly in cases in which, on
account of swelling of the lids, or for other reasons, the
eyes are not kept fully open. It may develop rapidly
with intense hyperemia, causing severe photophobia and
practical blindness, in a few weeks. The patient may
DISEASES OF THE CORNEA. 299
date the commencement of his eye trouble from the
beginning of the pannns, not counting the trachoma
which may have existed a long time previously. It con-
sists in great thickening, vascularity, and haziness of the
superficial layers, of those parts of the cornea which are
most continuously in contact with the lids. The part
always affected is the upper part of the cornea, sometimes
as far down as the center. In some cases a small area at
the lower margin is also involved. The usual distribu-
tion of the pannus is shown in Fig. 87. Sometimes it is
complicated with deep ulceration of the cornea.
Abrasions of the surface are frequent. In most cases
if the lids are comparatively cured, rendered smooth and
free from active disease, the pannus disappears, or is
reduced to a slight haziness, with a few inconspicuous
vessels. If, however, the lids have been much deformed
by the disease, and especially if they press upon the cor-
nea with permanent narrowing of the palpebral fissure,
the pannus may remain after the trachoma has ceased to
be active.
Diagnosis. — The portion of the cornea affected, and
the condition of the lids will distinguish pannus from
pterygium. The horizontal boundary quite separates it
from other vascular opacities of the cornea ; and a close
inspection of the vessels shows their characteristic forma-
tion. This, with other forms of corneal vascularity is
illustrated diagrammatically in Fig. 93.
Treatment. — In a large proportion of cases of pannus,
the only treatment required is that of the trachoma. As
the lids improve, the pannus improves equally, often
becoming unimportant long before the treatment of the
trachoma can be safely suspended. This is especially
the case when the trachoma is efficiently treated from a
period shortly after the development of the pannus. The
effect on the pannus of a thorough rolling of the lids is
sometimes very prompt and remarkable. But in chronic
cases special measures must sometimes be resorted to.
Photophobia and pain are usually much lessened by in-
stillations of atropin, or one of the other mydriatics. But
300 PANNUS.
it must be borne in mind that in a few persons these
drugs aggravate any form of conjunctivitis ; and trachoma
is no exception.
If there be marked shrinking of the pal pebral aperture,
and pressure of the lids upon the globe, canthoplasty should
be done. It increases the efficiency of applications for the
trachoma, and greatly lessens the traumatism to which the
cornea is continuously subjected.
Formerly inoculation of the eye with gonorrheal pus
was a recognized remedy for pannus. It was often effec-
tive in thinning the pannus, and the danger of corneal
perforation was much less than in the normal eye, on ac-
count of the vascularity of the cornea. But it has of
late years been replaced by the use of jequirity, which
produces much the same effect with less risk. It is ap-
plied either as an*infusion, lightly brushed on the inner
surface of the upper lid, or as an impalpable power dusted
on the same part (see Chap. XVIII). It produces a
sharp purulent, or croupous conjunctivitis, which runs its
course in a few days, leaving the lids and pannus decidedly
better.
Where severe pannus remains after the condition of
the lids seems no longer to furnish a sufficient cause for
it, the vascular surface may be curetted away, the ves-
sels may be closed as they pass on the cornea by burning
a line with the galvano-cautery, or peritomy may be done
(see Chap. XIX).
Persistent opacity that is almost non-vascular may
require other treatment given for the removal of corneal
opacities.
Prognosis. — Severe pannus is never followed by per-
fect recovery, but there may be restoration of good vision.
The ultimate condition of the cornea will depend largely
on that of the lids.
CORNEAL OPACITIES.
Causes and Varieties. — The physiological opacity
which may be brought out as a diffused haziness in the
DISEASES OF THE CORNEA. 301
normal cornea, and resolved under a strong magnifier
into separate dots and masses, must not be confused with
opacities due to disease. Arcus senifis is usually seen in
the aged, but sometimes in early life. It is a gray arc
separated from the upper and lower margins by a narrow
strip of clear cornea. It tends, with time, to become
denser, and to extend in a complete circle (see Fig. 95).
It is no contraindication to corneal operations, nor does
it indicate fatty degeneration in other organs.
A faint haziness of the cornea left by preceding inflam-
mation is a nebula, a spot of more decided gray opacity a
macula, and a dense cicatricial opacity, usually white in
color, a leukoma. The density of an opacity left by an
ulcer depends largely on its depth. Usually a perforat-
ing ulcer causes leukoma, and if the perforation has been
at all large, some part of the iris is apt to remain con-
nected with the scar, making it an adherent leukoma.
Such an opacity will often present a few rather large
vessels which arise from, or inosculate with, those of the
iris (see Fig. 96).
FIG. 95. FIG. 96.
FIG. 95.— Arcus senilis.
FIG. %.— Adherent leukoma, point of included pigment near its center, large
vessel extending on it from the conjunctiva, and pupil distorted by traction
on the iris.
Congenital opacity of the cornea occurs in the form
of minute scattered dots, probably due to intra-uterine
keratitis. Another form is that of a dense leukoma oc-
cupying the center of the cornea, and sometimes extend-
ing almost to the corneal margin. It is due to arrest of
the clearing of the cornea, which is all opaque at an early
stage of development. Sometimes these opacities greatly
diminish after birth. Another variety of central opacity
of the cornea, sometimes hereditary, has been known to
develop after birth.
302 CORNEAL OPACITIES.
Band-like opacity of the cornea occurs in two forms. A
very few old people, with eyes otherwise apparently healthy,
present a gray film covering the pupil, and occupying
most of the cornea! surface habitually exposed when the
lids are opened, the corneal margin remaining clear.
The opacity lies close to the surface, but the surface itself
remains smooth. Its appearance is illustrated in Fig. 97.
FIG. 97.— Band-like opacity of the cornea.
It is attended by no symptoms of irritation, but greatly
impairs the vision. Under cocain, the epithelium and
underlying film, which consists partly of lime salts, may
be scraped away, and the resulting abrasion treated with
solutions of boric acid and atropin. Band-like opacity
is also frequently seen in blind eyes which are undergoing
degenerative changes.
Family degeneration of the cornea causing opacity,
begins and is most dense near the center of the cornea,
while the extreme periphery remains comparatively clear.
The opacity may begin with dots " nodular opacity," or
with interlacing lines or streaks, "grill-like" or "lattice-
form " opacity. Later the whole mass of tissue becomes
opaque. It usually begins about puberty ; but sometimes
later in life. It is always bilateral and ultimately causes
practical blindness. Xo treatment except iridectomy, in
cases favorable for it, has proven beneficial.
Opacity following the prolonged application of a
lead-lotion to an abraded or ulcerated cornea, is of a
dense white color and situated just below the corneal sur-
face. It is usually said to be due to a precipitation of
some insoluble lead compound. Recently, however, some
films of the kind have been examined, in which no trace
of lead was found. Such opacities may be removed by
scraping. Sometimes they are thrown off spontaneously.
DISEASES OF THE CORNEA. 303
Gray opacity of the cornea occurs also from irido-
choroiditis, from contact of exudates with the posterior
surface of the cornea, and in glaucoma, and from burns
and other injuries.
Opacity of the cornea from staining with blood-pig-
ment occurs in some cases of extensive hemorrhage into
the anterior chamber. The cornea becomes of a smoky red-
dish-brown color, the cloud of discoloration being always
most dense at the center. The margin of the cornea
remains comparatively clear throughout, and in the end
the whole membrane usually clears up.
Pigmentation of the cornea occurs after chronic in-
flammation with increased tension ; points of previously
gray opacity becoming altered to black or brown pigment-
specks which may be permanent.
Symptoms. — Corneal opacity impairs vision, not only
by preventing properly focussed light from entering the
eye, but also, when strongly illuminated, by throwing
into the eye a large amount of diifused light, which
"drowns out" the impression of such focussed light as
may reach the retina. Any decided opacity of the cornea
is a personal disfigurement, to escape which patients fre-
quently seek the assistance of the surgeon.
Treatment. — Recent opacities following corneal in-
flammations continue to diminish spontaneously for
months or even years. Such diminution is partly by
alteration of new tissue into closer correspondence with
the normal tissue of the cornea, and partly by removal
of exudates. Certain mercurial preparations, especially
the ointment of the yellow oxid, and calomel dusted upon
the surface of the cornea, have a reputation for hastening
the latter process. " It should be remembered that calomel
should not be dusted in the eyes when potassium iodid is
taken internally ; for the iodid being largely excreted
through the tears, an intensely irritant compound is
formed which causes a violent conjunctivitis.
When the process of resorption comes to a standstill,
it can often be rendered active again by various decided
irritants. Thus massage with powdered boric acid, or
304 TREATMENT OF OPACITIES.
other substances, through the closed lid, or direct mas-
sage of the cornea may have the desired effect. Direct
massage of the cornea may be made with a corneal spa-
tula, or the back of a lens-spoon, using considerable pres-
sure over the spots of opacity, but not enough to provoke
severe or prolonged irritation. The massage should be
repeated at intervals of three days to two weeks.
Galvanic electricity may be used upon some chronic
opacities with decided benefit. The cathode applied to
the cornea should terminate in a metal cup which accu-
rately fits it, in which may be placed a drop of mercury.
The broad anode of sponge is applied to the cheek.
From \ to 1^ inilliamperes of current are to be applied,
for from one to three minutes. The application is made
under cocain ; and there should be little if any subsequent
irritation. It may be repeated every two or three days.
In adherent leukoma, the greatest diminution in the
opacity will be brought about by dividing the adhesions
of the iris to the cornea. An operation accomplishing
this often causes enlargement of the pupil, and the ad-
mission of a greater amount of diffuse light, by which
vision is made wrorse rather than better. To diminish
the light admitted through the hazy part of the cornea,
tattooing has been advocated (Wecker). To secure a
pupil removed from the corneal opacity, optical iridec-
tomy may be resorted to. If the patient is practically
blind before, he may be greatly benefited by optical
iridectomy ; but if he previously possessed moderate
vision, the operation is apt to be disappointing. Trans-
plantation of the cornea from one of the lower animals is
only applicable to the very rare cases of dense permanent
central opacity, in which there has been no perforation
of the cornea ; and in these it has been of little practical
value. When the eye is entirely blind, tattooing of the
cornea or enucleation or evisceration of the eye may be
done for cosmetic reasons.
Prognosis. — Decided opacity of the cornea, especially
if it extend deeply, rarely or never clears up entirely.
The greatest improvement is seen in early childhood,
DISEASES OF THE CORNEA. 305
especially after interstitial keratitis. When dense opacity
has to a great extent cleared up in early life, it may
partly return, with the degenerative changes of old age.
Even eyes that have become free from noticeable corneal
opacity, generally retain enough irregular astigmatism to
greatly impair vision.
PROTRUSIONS OF THE CORNEA.
Anterior Staphyloma (Corneal Staphyloma).—
Causes. — After a large perforation of the cornea, and
extensive prolapse of the iris, the portion of iris remain-
ing embedded in the scar-tissue which replaces the cornea,
drags the other parts of the iris in close contact with the
corneal margin, and effectually closes the chief outlet for
intra-ocular fluid (see Chap. XV). The scar also, being
relatively less resistant than the normal solera, often
gives way before the intra-ocular tension and bulges.
Prolapse of the iris always bulges when it occupies a
perforation ; but later the deposit of new tissue, and its
cicatricial contraction, usually flattens it down. At this
stage the intra-ocular fluid still finds sufficient avenues of
escape. Later still, when the same cicatricial contraction
has drawn the whole iris into closer contact with the cor-
nea, and has consolidated the tissue, rendering it com-
paratively impervious to intra-ocular fluids, the pressure
within the eye rises to such an extent as to cause the
secondary distention designated staphyloma. Or the dis-
tention may remain throughout, while the scar-tissue
thickens up and the prolapse, without material change of
shape, becomes a staphyloma. When the whole cornea
becomes involved in the process, the case is said to be
one of total staphyloma, when part of the cornea remains
comparatively unaltered it is partial staphyloma.
Symptoms. — Decided anterior staphyloma causes so
much protrusion, that its presence and movements may
be recognized through the closed lids ; and if very large
it renders complete closure of the lids impossible. The
most prominent portion of the staphyloma protruding con-
20
306 ANTERIOR STAPHYLOMA.
tinuously between the lids becomes red and irritated, or
dry and skin-like in appearance. The staphyloma is
always opaque ; but if very recent it may be so thin
that the dark pigment-layer lining it shows through, giv-
ing it a grayish-purple color,
the resemblance of which to
that of a ripe grape gave the
name to this condition. Usu-
a^7 this color is gradually lost,
the most of the scar becoming
rather white, with some few
vessels in it ; and perhaps one
or more masses of black pig-
ment from the incarcerated iris.
The margin of the staphyloma
(wnat was the margin of the
cornea) may remain partly
transparent; and through this the iris is apt to give a
blue-gray color. The appearance of corneal staphyloma
is illustrated in Fig. 98.
The rubbing of the lids by the protruding mass may
cause symptoms of irritation ; or the simple stretching or
pinching of nerves in the scar-mass may cause pain. The
protrusion may remain stationary for months or years;
but it is always liable to give way before the intra-ocular
pressure and become more distended. The pressure is
especially eifective at the re-entering angle, where the
staphyloma joins the normal outline of the eyeball.
Partial staphyloma, therefore, tends to become total ; and
total to increase, so that a staphyloma once covered by the
lids comes to protrude between them. If allowed to go
on, the process ends in rupture of the weakest part of the
staphyloma, and escape of a large amount of aqueous
humor. After this, the staphyloma partly collapses, the
rent closes, and the distention again occurs. This may be
repeated, but ultimately the rupture is apt to set up a gen-
eral inflammation of the uveal tract, which ends in shrink-
ing of the eyeball. Sometimes a corneal staphyloma
leads to general distention of the eyeball.
DISEASES OF THE CORNEA. 307
The opacity of total staphyloma always causes blind-
ness. Even if some part of the cornea remains clear in
partial staphyloma, it is usually so distorted as to allow
very imperfect vision. If the staphyloma be progressive
all useful sight may be lost. Eyes, so blinded, retain
good perception of light often for many years, especially
in children, where the distensibility of the sclera long
saves the retina from loss of function through pressure.
A child with double staphyloma will often find great
enjoyment in holding its spread fingers between its eyes
and the light, and moving them from side to side to get
the eifect of the alternate light and shadow.
Diagnosis. — Corneal staphyloma will be easily distin-
guished from the other kinds of opacity of the cornea by
the marked departure from the normal outline of the eye-
ball. From new growths affecting the front of the eyeball
it may be known by the comparative absence of vascular-
ity, the whiteness of the center, in contrast with the blue-
gray margin, and the history of antecedent inflammation
and long continuance without much change of appearance.
Then, too, in staphyloma the sclera is evidently contin-
uous with the tumor; not overlaid or burst through as
in the case of a new growth.
The diagnosis between total and partial staphyloma
must be made on account of the difference in prognosis
and treatment. The chief difficulty lies in the deceptive
appearance of clear cornea with the iris behind it, presented
by the margin of a total staphyloma. Unless an appre-
ciable depth of anterior chamber can be made out between
the periphery of the cornea and the iris, the staphyloma
must be regarded as total.
Treatment. — Partial staphyloma, without tendency to
increase, is sometimes best let alone. Even if the vision
of the affected eye might be improved by iridectomy, this
will probably be no help to. the patient if he has good
sight in the other eye, unless the iridectomy will extend
his field of vision. Otherwise, the imperfect retinal
images gained by the iridectomy are likely only to inter-
fere with his use of the more perfect retinal images
308 ANTERIOR STAPHYLOMA.
formed in the other eye. If, however, the other eye is
blind, or both are seriously impaired, there is every reason
to give the best sight possible by doing i rid ectoray where
it will allow light to enter the eye through a pupil placed
behind the clearest and most regular part of the cornea.
If the staphyloma has long been stationary, and is not
very extensive, the iridectomy may be solely for optical
effect, and as small as it can readily be made in the re-
quired situation. If the staphyloma is at all progressive,
or is very large or quite recent, it will be better to make
a large iridectomy, and to carry it well to the ciliary mar-
gin of the iris to secure its utmost influence in keeping
down intra-ocular tension, and preventing extension of the
staphyloma.
For total staphyloma, nothing can be done that prom-
ises restoration of sight. The indications are simply for
the prevention, or diminution of disfigurement or discom-
fort. These indications may also justify similar opera-
tions in partial staphyloma. Tattooing may be done to im-
prove the appearance of the eyeball ; or, if distention is
going on, incision or excision may be practiced (see Chap.
XIX). For a thin staphyloma that will collapse
when punctured an incision may be enough. For a
thicker, unyielding staphyloma, excision of a portion,
usually the greater portion, will be better. Where, in
spite of this operation, the tendency to distention con-
tinues, especially if there is with it a tendency to dis-
tention of the sclera, evisceration or enucleation of the
eye must be resorted to.
Prognosis. — In total staphyloma, restoration of any
useful vision is quite impossible. Even light-perception
is likely to be ultimately lost by prolonged pressure on
the retina; and degeneration of the eyeball, or the effects
of rupture, may necessitate its removal. In partial
staphyloma, even a very small piece of clear cornea may
allow restoration from complete blindness to useful
vision ; and patients who are thus blind appreciate even
slight improvement. But it must be remembered that an
eye with even a small corneal staphyloma is seriously
DISEASES OF THE CORNEA. 309
damaged, and especially vulnerable to various injurious
influences.
Keratectasia (Ectasia of the cornea) is a giving way
of the cornea, due to lessening of its relative resisting
power, by disease which also causes corneal opacity, with-
out there having been a previous perforation of the cor-
nea, or inclusion of the iris in a scar. If small and
recent, puncture of the cornea, especially with the gal-
vauocautery, may be tried. If extensive and old,
tattooing or enucleation may be indicated.
Conical Cornea (Keratoc&nus.} — Disturbances of nu-
trition that attract attention to the eyes in no other way,
may so weaken the cornea that it will give before
the intra-ocular pressure. The point of greatest weakness,
which is usually a little below the center of the cornea, is
forced forward, and becomes sharply curved. While
around it, the cornea assumes a rather conical form. Fig.
99 shows the general outline of the cornea in a section
Fiu. 99. — Diagram of conical cornea. The dotted lines show the normal curve
of the cornea.
through the apex of the cone. Conical cornea arises
usually before the age of twenty, sometimes after an
attack of exhausting disease, sometimes under the strain
of school-work. If the protrusion is moderate, the cornea
remains clear, or only shows a slight opacity on oblique
illumination. If the protrusion is extreme (it sometimes
amounts to a half-inch or more), the opacity is more
noticeable. The protrusion usually occurs in both eyes,
and continues to increase for a time, and then becomes
stationary. But it may again change in later life.
310 CONICAL CORNEA.
Its most important effect is its influence on the refrac-
tion of the eye. The apex of the cone, from its increased
curvature and displacement forward, is rendered very
highly myopic ; while the sides of the cone, by their
flattening, balance the forward displacement so that toward
the edge of the pupil the eye will be but slightly
myopic, or even hyperopic. This causes high aberration
(see p. 186), and the appearance of the light and shadow
in the pupil long recognized as characteristic of conical
cornea, which is shown in Fig. 100. The error of refrac-
FIG. 100.— The skiascopic appearance in the high aberration of conical cornea.
tion always makes vision imperfect, and only rarely can
it be corrected by lenses so as to give vision approaching
the normal standard. The lenses giving best vision are
usually strong concave sphericals, combined with very
strong cylindricals. If the conicity is of high degree,
and increasing, it is proper to attempt to check it by
operation. This may be the excision of a small lens-
shaped piece from the apex of the cone, or by touching
and perforating the apex with the galvanocautery.
KeratoglobtlS. — When, instead of giving way at
one part, the cornea distends uniformly before the intra-
ocular pressure, this condition results. Besides being
pushed forward, the cornea is enlarged laterally, so that
it may be 12 or 15 mm. in diameter, instead of the nor-
mal size of 10 to 11 mm. The eye looks prominent, the
anterior chamber is very deep, the iris looks flat, the
pupil is small. Usually the refraction is quite myopic.
DISEASES OF THE CORNEA. 311
Both eyes are commonly affected. The condition may
attract no special attention, being regarded simply as a
personal peculiarity. It develops in early life. Correc-
tion of the error of refraction is the only treatment
required. Keratoglobus is also a symptom of buphthal-
mos (see Chap. XV).
Tumors originating in the cornea are extremely
rare, although it may be involved in growths starting in
the conjunctiva, or penetrating it from the interior of the
eye. Dermoid tumor of the junction of the cornea and
conjunctiva is not so rare. It is congenital, but may grow
after birth. It occurs most frequently at the temporal
side, lying partly on the cornea and partly on the con-
junctiva. It has the color and appearance of a piece of
skin, and often presents numerous small hairs, which may
cause irritation of the lids. Removal of the tumor may
be indicated for cosmetic reasons. It is done under
cocain by simply dissecting it off from the cornea and
solera ; and drawing the conjunctiva as much as possible
over the denuded surface.
Burns of the cornea, either by heat or caustics, by
causing coagulation and opacity of the superficial layers,
appear serious, even when slight. They may cause deep
sloughing, or, in connection with burn of the conjunctiva,
a subsequent symblepharon. Those by lime are frequent
and serious. They must be treated by thorough cleansing
and a protective dressing (see p. 272).
Wounds and foreign bodies in the cornea are considered
in Chapter XVII.
DISEASES OF THE SCLERA.
Scleritis (Sclerotitis, Episcleritis). — Inflammation of the
solera occurs from the causes of inflammation in white
fibrous tissue in other parts of the body, exposure, gout,
rheumatism, syphilis, scrofula, " disturbed menstruation,"
and more obscure errors of nutrition. Two forms are
recognized, a superficial (episderitis) and a deep inflamma-
tion. The former leaves the eye uninjured ; but the latter
312 SCLERITIS.
may extend to the deeper coats of the eye, and by intra-
ocular lesions injure the sight.
Symptoms. — The hyperemia and swelling are com-
monly limited to one or more round patches, of a dusky- or
purple-red, due to deep hyperemia, over which pass enlarged
conjunctiva! vessels. The affected spot' is decidedly
prominent from the swelling, and may be tender to touch.
The accompanying pain varies greatly, being in some cases
trifling, in others very constant and severe. The swell-
ing and discoloration usually subside slowly after many
weeks, often leaving a spot of bluish discoloration, which
may be slightly depressed, or which may become dis-
tended, causing a staphyloma. A marked characteristic
of the disease is its tendency to recur again and again,
and in spite of all treatment.
Diagnosis. — Hrom phlyctenular conjunctivitis it is
distinguished by the more dusky or purple color of the
hyperemia, and its depth, and chronic course ; and in
some cases by the absence of pain and photophobia, also
by the age of the patient. The cases of scleritis most
resembling phlyctenular disease occur in adults or elderly
people. From iritis and keratitis, it is distinguished by
absence of changes in the iris or cornea, except when
complicated by sclerosing keratitis. The deep cases are
to be distinguished from the superficial by the wide
extent of the hyperemia.
Treatment. — Locally bathing the eye with very hot
water, and instillations of atropin are generally of benefit.
Massage, gentle during the acute hyperemia, and more
vigorous at a later stage, is also of value. Touching the
affected part from time to time with the actual cautery
has been useful in some cases. The general treatment is
important. Syphilis, gout, rheumatism, or intestinal
auto-intoxication should receive careful attention. Diet,
habits, and manner of living must be regulated if pos-
sible ; and change of climate, or residence at some spa
may be worth trying, in view of the liability in cases of
deep inflammation to scleral staphyloma or intra-ocular
lesions that may destroy the sight.
DISEASES OF THE SCLERA. 313
Staphyloma of the Sclera (Partial Scleral Ec-
f,asia). — Weakening of the scleral coat by injury, deep
scleritis, gumma of the ciliary body, or in connection
with choroiditis, may cause the distention of the weak-
ened part before the intraocular pressure. Or abnormal
increase of intra-ocular tension may do the same thing
with the normal sclera. The lesion is named according
to location, a ciliary, equatorial, or posterior staphyloma,
or ectasia. The bulging is readily perceived anteriorly ;
and by focal illumination, the thinness of the sclera may be
demonstrated. Posterior staphyloma is recognized and
studied with the ophthalmoscope (see p. 162). Nothing
except removal of causes can be done in the way of treat-
ment, since the disturbance of nutrition that allows such
distention makes operative interference dangerous or use-
less, unless sight has been lost. Then enucleation or some
substitute may be necessary.
Buphthalmos is a general dilatation of the sclera,
which begins in childhood, and usually progresses until
vision is entirely lost. (See Chap. XV.)
Injuries of the sclera are considered in Chapter XVII.
CHAPTER XI.
DISEASES OF THE IRIS, CILIARY BODY, AND CHO-
ROID; SYMPATHETIC OPHTHALMIA.
THE iris, ciliary body and choroid, constitute together
the u veal tract, the vascular, or nutritive coat of the eye.
The close anatomical and physiological relations of its
different parts demand that their diseases should be con-
sidered together, not only in the text-book, but equally in
the ordinary clinical work of diagnosis and treatment.
Their vital importance to the non-vascular transparent
tissues, the vitreous, crystalline and aqueous, which de-
pend on the uveal tract for their nutritive supply, is also
to be born in mind in connection with loss of trans-
parency or other disease in those tissues.
314 IRITIS AND CYCLITIS.
UVEITIS.
Inflammation of any part of the uveal tract might prop-
erly be termed a uveitis. The important practical point
is that when inflammation seriously attacks one part of
the uveal tract, other parts do not entirely escape. It is
generally understood that tenderness of the eyeball,
observed in connection with iritis, is due to involvement
of the ciliary body. Inflammation of the ciliary body
without involvement of other portions of the tract is
known to be rare, and relapsing inflammation of the
choroid is liable to become complicated by irido-cyclitis.
While it is convenient to describe and classify iritis, cyclitis
and choroiditis as separate diseases, one must remember
in clinical work that each is a form of uveitis and that
oth^r forms of uveitis are very likely to accompany it.
Another fact of *the greatest clinical importance is that
back of every case of uveitis is some general disease or
diathetic state, like syphilis, rheumatism, intestinal auto-
intoxication, etc., and that success in dealing with the
ocular lesions will depend chiefly upon the recognition
and mastery of the general condition from which it springs.
So true is this, and so important is it, that the absence of
the more common constitutional causes for uveitis should
only stimulate the search for the rarer condition which
may be responsible for this particular case. If there be
no evidence of syphilis or rheumatism, one should
immediately consider the possibilities of diabetes, chronic
nephritis or chlorosis ; and auto-intoxication of unusual
character remains as a possible explanation when other
general conditions are excluded. Even in cases of
traumatic uveitis the outcome depends more frequently
upon the general condition of the patient than upon the
extent of the wound, or the bacteria which have invaded it.
IRITIS AND CYCLITIS.
Iritis. — Causes. — Of all cases of iritis one-half are
caused by syphilis, one-fourth by rheumatism, including
a group of allied conditions of nutrition ; and most of
the remainder by gout, traumatism, preceding febrile dis-
DISEASES OF THE IRIS. 315
eases, certain cachexias, gonorrhea, diabetes, and new
growths in the iris, with a frequency diminishing in some-
what the order named. Eye-strain is also a cause of some
importance. The conjunction of two or more of these
causes increases the liability to iritis, although in many
cases a conjunction of causes is not perceptible.
Symptoms and Course. — A typical case of iritis be-
gins with discomfort in the eye, which usually increases
to a distinct ache referred to the brow immediately above
the eye. With this there is often increased secretion of
tears, and the eye becomes reddened. The hyperemia
may to some extent involve the conjunctival vessels, espe-
cially if the eye is kept covered or bandaged ; but its
constant characteristic is the marked pericorneal zone (see
p. 61), illustrated in Figs. 18 and 101. This zone, com-
FIG. 101.— Iritis with contracted, irregular pupil and pericorneal zone.
mencing as light pink, becomes more pronounced as the
severity of the attack increases, and its color deepens
toward a brick-red or a dark purplish hue. When the
pericorneal zone is well marked there is generally dis-
coloration of the iris (see p. 71), loss of luster and indis-
tinctness of its surface, and contraction of the pupil, with
irregular dilatation in the dark-room.
As the case goes on, the pain becomes more severe,
being worse at night, and preventing sleep. It is referred
to the eyebrow, nose, or the whole front of the head, is
of an aching character, usually severe ; and only in rare
cases slight or absent. It continues until the height of
the disease is passed, and may be felt as an occasional
discomfort after the inflammation has ceased. The eye
may also be tender on pressure, although this is associated
chiefly with cyclitis.
The pericwneal redness continues usually until after the
316 SYMPTOMS OF IRITIS.
pain has become inconstant or has passed away. In the
latter stages it varies greatly with the exposure of the eye
to irritant influences ; and after the eye seems free from
redness, a little manipulation of it, or exposure to air or
strong light, or even simply directing attention to it by
inspection, may cause the appearance of marked hyperemia
in a few minutes. Such an eye is said to be irritable ; and
the condition of undue irritability may continue for one
or two weeks after the cessation of constant hyperemia.
The blurring and alteration of appearance of the iris-
surface increase with the severity of the inflammation.
They are due to changes in the structure of the iris itself,
particularly its anterior epithelial layer ; and also to hazi-
ness and discoloration of the aqueous humor by exuda-
tion.
The contraction9 and fixity of the pupil become more
marked, unless overcome by a mydriatic ; and its form
becomes irregular. These changes of form are due to
hyperemia of the iris, exudate into the iris-tissue, and
adhesion of the iris to the lens-capsule. They are illus-
trated in Figs. 101, 102, and 103 ; and are always most
^H^^
ABC
FIG. 102.— Iritis. A, with pupil contracted; B, with pupil dilated, showing
adhesions of the iris to the lens-capsule; C, with pupil dilated, as seen with
the ophthalmoscope.
noticeable when the pupil is most under the influence of
a mydriatic. They should be studied by oblique illumi-
nation and with the ophthalmoscope.
Adhesions between the lens-capsule and the iris usually
form first at isolated points of the margin of the pupil ;
but they may extend along the whole pupillary margin,
or to a large part of the posterior surface of the iris. At
the points of adhesion the iris is prevented from retracting
when subjected to the influence of a mydriatic, and these
DISEASES OF THE IRIS. 317
points appear projecting into the dilated pupil, as in Fig.
102. In contrast with the above, hyperemia or exudation
in a limited portion of the iris causes a rounded projection
into the pupil, as shown in Fig. 103.
o
ABC
FIG. 103.— Iritis, pupil distorted by local swellings of the iris. A, pupil con-
tracted; B, pupil dilated; C, as seen with the ophthalmoscope.
The adhesions of the iris to the lens-capsule, posterior
synechice, are at first very weak and easily broken. Hence
the early use of a mydriatic may cause sufficient pull
upon them to break them, a portion of the exudate
remaining as an opaque brown spot upon the lens-capsule.
A number of such spots often mark what has been the
margin of the pupil before dilatation. Later, when they
have become partly organized, the same pull may stretch
the synechia ; the iris retracting, but still retaining a
connection with the lens-capsule by a thread of adhesion.
But the exudate tends to undergo organization into firm
connective tissue. When this has occurred, the retractile
force of the iris, even under the strongest mydriatic, is
unable to sever or stretch the synechia, and the iris
ABC
FIG. 104.— Pupil distorted by iritic adhesions. A, on first use of mydriatic;
B, adhesions stretched and one broken off; C, all the adhesions broken loose
but two, leaving a ring of dots of exudate on the lens-capsule.
remains permanently bound down. The effects of these
different conditions on the appearance of the pupil, when
subjected to a mydriatic, are shown in Fig. 104.
In a large number of cases, even if the exudate causes
318 SYMPTOMS OF IRITIS.
no posterior synechia, it appears as a precipitate on the
posterior surface of the cornea, the so-called keratitix
punctata, to be referred to under cyclitis (page 324).
Although not a characteristic symptom, impairment of
vision almost always occurs in iritis. It is most constantly
due to clouding of the dioptric media, either the cornea
or the vitreous may be affected, and the aqueous is almost
always altered. Synechia? are also likely to cause more
or less opacity of adjoining portions of the crystalline
lens. In some cases the iritis is followed by a myopia
which may last for several weeks or months. The dilata-
tion of the pupil by a mydriatic adds to the impairment
of vision. The tension of the eyeball is generally not
markedly altered in acute iritis ; but it may become so in
acute or recurrent attacks, when certain conditions dis-
cussed in Chapter XV arise.
The subsidence of iritis is shown by diminution of the
pain and hyperemia, and better dilatation of such parts
of the pupil as are not bound down firmly by the synechia?,
such dilatation depending on lessened hyperemia, or the
removal of the exudate from the tissue of the iris, or
both. A renewal of the inflammation is indicated by
symptoms similar to those of the original attack. Re-
lapses are quite liable to occur, especially if the causative
condition has not been entirely remedied.
Varieties. — The form of iritis described above is called
simple or plastic iritis. It is closely allied with parenchi/-
matous iritis, in which the exudation being chiefly within
the tissue of the iris causes marked swelling. Purulent
iritis is usually associated with similar disease of other
parts of the uveal tract. It occurs with acute infectious
diseases, meningitis, pneumonia, or pyemia. It may
cause hypopyon. When in plastic iritis the exudate
is so abundant that it coagulates, forming a grayish
mass in the anterior chamber, which may be mistaken for
a dislocated lens, the case is said to be one of spongy,
orfibrinous, iritis. Quiet or insidifts iritis, occurs chiefly
in anemic, poorly-nourished women approaching middle
life. It is attended with no pain, and the hyperemia is
DISEASES OF THE IRIS. 319
so slight as sometimes to pUss unnoticed. The patient
comes for impairment of sight, and the iris is found firmly
bound down to the lens-capsule. This form has been
designated uveitis, on the supposition that only the pos-
terior or uveal layer of the iris is inflamed. The serous
iritis of older authors is here described as cyclitis. Iritis
is also divided into varieties according to its causation.
Syphilitic iritis occurs as one of the secondary lesions
of that disease, mostly within the first year after the in-
fection. In the majority of cases both eyes are affected.
It always becomes plastic, although at first it may appear
serous, and it is often also parenchymatous, being marked
by the formation of small papules or condylomata near
the margin of the pupil. A rather similar form appears
in hereditary syphilis during the first year of life. An
iridocyclitis often accompanies interstitial keratitis, or it
may occur alone as a tertiary lesion of acquired or in-
herited syphilis. More or less iritis attends the forma-
tion of gum ma in the iris (see page 330). Syphilitic iritis
properly treated is not especially liable to recur.
Rheumatic iritis may accompany an outbreak of acute
articular rheumatism, may alternate with attacks of sub-
acute rheumatism, or may occur after special exposure as
the only manifestation of the diathesis. It is attended
with severe pain and hyperemia, often affects but one eye,
and is especially liable to recur. It is marked by the
early formation of synechiae, which, however, are narrow
and easily torn asunder or stretched under the influence
of a mydriatic.
Gouty iritis, arthritic ophthalmia, resembles rheumatic
iritis, but is usually less violent. Iritis sometimes accom-
panies chronic interstitial nephritis. Auto-intoxication of
some kind should be considered as a cause of iritis.
Gonorrheal iritis may occur with acute gonorrheal
rheumatism, as a violent plastic iritis ending in recovery,
with comparative freedom from sequels. Or it may
occur at a later stage as a less violent iritis with a strong
tendency to relapse. Diabetic iritis is marked by ex-
tensive exudate, which is usually fibrinous but may be
320 VARIETIES OF IRITIS.
purulent, and which generally clears up very well under
treatment. The possibility of diabetes should be borne
in mind in all cases of iritis of obscure causation. Oph-
thalmia nodosa may involve the iris with the formation
of nodules in its tissue (see page 243).
Traumatic iritis may arise from direct injury or the
lodgement of a foreign body in the iris ; or it may follow
bruise without any perceptible lesion within the eyeball.
New growths involving the iris generally give rise to
inflammation. Glaucoma of the inflammatory type is
constantly attended by iritic inflammation. Inflamma-
tions of the cornea, as well as those of the ciliary body
and choroid, are liable to involve the iris.
Diagnosis. — The diagnosis of iritis rests on visible
changes in the iri* A careful examination of the eye by
oblique illumination and with the ophthalmoscope, and the
careful testing of mobility of the iris and pupil are essen-
tial. It is to be distinguished from cyclitis by the absence
in the latter of changes in the iris itself, although the
other symptoms of iritis are present. Keratitis is dis-
tinguished from iritis by discovering changes in the cor-
nea, such as haziness, localized opacity or ulceration,
without alteration in the iris, except such change of color,
and blurring of detail as the corneal haze would cause.
When keratitis occurs in an eye presenting alterations of
the iris due to a preceding iritis, or iritis attacks an eye
having corneal opacities or irregularities, the differential
diagnosis may be impossible.
In conjunctivitis the redness is conjunetival (Fig. 16) or
phlyctenular (Fig. 17), not pericorneal (Fig. 18); the
pain is smarting, burning or the feeling of a foreign body,
not aching ; and is confined to the eye, not referred to
the brow, nose or cheek as in iritis ; the iris is unaltered
in appearance or reaction ; and the vision is generally
unaffected. The differential diagnosis from glaucoma is
extremely important. It is discussed in connection with
that affection (Chapter XV).
When iritis follows traumatism, one must make sure
that it does not mask more serious lesions. And as it
DISEASES OF THE I&IS. 321
attends new growths in the iris and in deeper parts of
the eye, the recognition of the iritis must not prevent the
search for such more serious causes. The diagnosis of
the different varieties of iritis rests on points mentioned
in describing them.
Treatment. — The treatment of iritis includes : the
removal or treatment of its cause, the subjection of the
iris to the influence of a strong mydriatic, the relief of
pain, antiphlogistic measures, and the improvement of
the general health and nutrition.
General Treatment. — Mercury is of special value in
plastic iritis. The author prefers to begin with calomel
in doses of -| to |- grain, three or four times a day, con-
tinued until they produce a decided effect on the bowels,
or other evidence of the general action of the drug. After
this the mercury may be continued in a different form
(see Chapter XVIII), for syphilis, or discontinued in
the non-syphilitic. Where rheumatism is the cause, saly-
cilates should be given freely. The patient should keep
dry and warm, and the Turkish bath, or exposure of the
surface to superheated air may be beneficial. The diet
should be regulated to the exclusion of whatever is im-
perfectly digested. A gouty iritis requires regulated
diet, excluding all alcoholic drinks, acid fruits, and all
articles known to have produced previous gouty attacks,
and much meat. Alkalies and alkaline waters may be
given freely, with colchicum, or piperazin. For iritis in
the diabetic, the regulation of the diet becomes of chief
importance. Gonorrhea! iritis should be treated much
like that due to rheumatism, with the 'addition of careful
attention to any urethral discharge. Malarial iritis re-
quires quinin in large doses, and sometimes arsenic.
Many who suffer from iritis are distinctly anemic and
poorly nourished, or even cachectic. Such patients
should have tincture of chlorid of iron in full doses,
and tonic doses of the cinchona alkaloids. In its later
stages plastic iritis is often benefited by the internal use
of moderate doses of potassium iodid. If the iritis be
violent, the patient will do best to remain in bed. In
21
322 TREATMENT OF IRITIS.
any case he should avoid fatigue or exposure. Sudden or
great changes of light must be avoided, but confinement
in darkness is not advantageous. Intestinal auto-intoxi-
cation requires attention to diet, and exercise.
Local Treatment. — The eye should be brought quickly
and completely under the influence of one of the stronger
mydriatics. Atropin is probably best, because of the
slower recovery from it, and its slighter tendency to
cause constitutional symptoms. Its action may be greatly
assisted and hastened by the simultaneous instillation of
cocain (see Chapter XVIII). Since it is of great im-
portance to secure dilatation of the pupil, and the danger
of mydriatic intoxication limits the amount of the drug
that can be used at one time, it is often well, even when
both eyes are affected, to make the chief mydriatic attack
on one eye one day, and the other the next. The cocain
is to be used in such a mydriatic attack. If a good dila-
tation of the pupil be not secured at first, it may be well
to repeat the mydriatic attack a few days later, when the
use of mercury may have weakened the adhesions, or
may have reduced the hyperemia or exudation in the iris.
After the best dilatation of the pupil has been obtained,
it is to be kept up by the use of so much of the mydriatic
as may be necessary. This may require at first the use
of the strong solution four to six times a day. Later, a
weaker solution may be used, and one to three instilla-
tions may suffice. The use of the mydriatic should usually
be continued until the eye is entirely free from redness,
or irritability. A few cases of iritis, usually complicated
with severe cyclitis,* do better if the mydriatic is discon-
tinued early, as after two or three days.
Next in importance is the local application of heat.
Cold may be of benefit in traumatic cases during the first
twenty-four hours after the injury, but otherwise it does
little good in iritis. Hot applications are better. These
may be by bathing the eye and surrounding parts wi.th
water as hot as can be borne, immediately before the in-
stillation of the mydriatic, or when the eye becomes
especially painful ; or the continuous use of dry heat by
DISEASES OF THE IRIS. 323
the hot-water coil or some form of electrical heater.
Heat lessens hyperemia and pain. Dionin may also be
used as an analgesic by placing the powder in the con-
junctiva once or twice in the twenty-four hours.
Local bleeding from the temple, either by the natural
or the artificial leech, also controls pain ; and is often the
starting point for progressive improvement. It is of use
chiefly in the more acute cases attended with acute pain.
It may be repeated on successive days, or even more fre-
quently, if the pain recurs (see Chapter XVIII). In
general, the eye should not be bandaged, unless this is
needful to protect it against severe cold.
If the relief of pain be not effected by the local treat-
ment, it may be best to give analgesics, like opium, or
acetanilid, a little before bed-time to secure as much sleep
as possible ; for loss of sleep may seriously hinder reso-
lution. For the sequels of iritis see page 326.
Prognosis. — When an iritis is seen early, the patient
should be warned of the serious nature of the attack, the
danger of permanent damage by iritic adhesion, that the
eye is likely to become more inflamed and painful before
it begins to get better, and that several weeks or months
may be required for complete recovery. The results of
an attack depend largely on treatment; but also upon
constitutional conditions that cannot be exactly appre-
ciated. While partial restoration to normal generally
occurs, complete restoration is exceptional. Recurrence
and relapse are most common in the insidious iritis of the
cachectic, especially of anemic women. They are also
common in rheumatic and gouty iritis. They are rare
after well-treated syphilitic iritis. Although the recovery
of the iris may be complete, concomitant lesions, as of the
cornea, ciliary body and the choroid, may cause perma-
nent damage. An attack of even simple iritis may lead
to such changes or sequels as will totally destroy the use-
fulness of the eye. Yet sometimes an eye, blind as the
result of iritis, may be restored to great usefulness by proper
operative treatment. In few diseases is an early positive
324 PROGNOSIS OF IRITIS.
definite statement as to the ultimate result more rash and
worthless.
Cyclitis (Serous Iritis, Iridocyclitis, Keratitis Punc-
tate^.— Most cases of iritis show some extension of in-
flammation to the ciliary body ; and in but few cases of
cyclitis does the iris entirely escape. Yet some points
regarding cyclitis should be considered separately.
Symptoms, Causes and Varieties. — The severe pain
and pericorneal hyperemia resemble those of iritis, and
the vision is impaired, equally or to a greater extent, on
account of opacities in the vitreous. In severe acute
cyclitis the ciliary region becomes very tender to touch.
The causes are the same as those of iritis, but traumatism,
eye-strain and syphilis are relatively more important.
The recogni/ed varieties are about like those of iritis.
In plastic cyclitis there is exudate into the ciliary body
and the vitreous, with great danger of subsequent cicatri-
cial changes. Purulent cyclitis is associated with puru-
lent choroiditis (see page 343).
The most characteristic symptom is the deposit of exu-
date on the posterior surface of the cornea, usually called
keratitis punctata. The deposit consists of cells, fibrinous
material, and micro-organisms. It is distributed usually
in isolated dots arranged in a triangle, with its base at
the lower margin of the cornea, and its apex upward.
This is shown in Fig. 105. The dots are larger and
closer together in the lower part of this space ; and if
there is a large amount of exudate they coalesce, forming
A B
FIG. 105.— Deposits on posterior surface of the cornea, so-called keratitis
punctata: A, as seen by oblique illumination (the spots are never white, but
gray or even dark brown); and B, as seen with the ophthalmoscope.
irregular masses. At first the cornea on which they are
deposited is unaltered. But if they remain long in con-
DISEASES OF THE CILIARY BODY. 325
tact with it, each spot gives rise to opacity in the
posterior layer of the cornea itself, which may remain
permanently. Deposits of similar material sometimes
occur on the anterior surface of the iris and lens-capsule.
The pupil in cyclitis may be somewhat sluggish, but is
not contracted unless some iritis or hyperemia of the iris
is present. The periphery of the iris may be retracted,
increasing the depth of the anterior chamber, especially
late in plastic cyclitis.
The tension of the eyeball is apt to be slightly increased
in the early stages of the cyclitis, and much elevated if
secondary glaucoma supervenes. In chronic cyclitis
without glaucoma the tension is often much lowered.
Diagnosis. — Cyclitis may be recognized by the same
symptoms as iritis, with the spots of exudate on the
posterior surface of the cornea, and the tenderness of the
ciliary region. Without these latter the case may be
regarded as one of iritis without cyclitis. On the other
hand, if in spite of the other symptoms the iris presents
no visible alteration, the case must be classed as cyclitis
without iritis. Probably the myopia often observed after
iritis depends rather on the changes in the ciliary body.
In some cases of iritis, neither marked changes in the iris,
nor the formation of synechias occur for several days, the
case at first appearing like cyclitis. But in such cases it will
be found that mydriatics show less power to dilate the
pupil than in the normal eye, on account of hyperemia
already existing in the iris. Syphilitic iritis often shows
this peculiarity. Cyclitis is liable to be confused with
keratitis, and conjunctivitis, and most of what has been
said of the differentiation of these affections from iritis
will apply here. It must also be distinguished from
glaucoma (see Chapter XV).
Treatment. — This is the same as the treatment of
iritis, except in respect to the use of mydriatics. Most
cases of cyclitis complicated with iritis do well under a
mydriatic. Some cases of simple cyclitis are equally
benefited by mydriatics. But a few cases of cyclitis do
badly under a mydriatic. Hence mydriatics must be
326 TREATMENT OF CYCLITIS.
used cautiously, and sometimes discarded altogether. On
this account the briefer mydriatics, duboisn, hyoscyamin
and scopolamin, are decidedly preferable to atropin,
and even homatropin may be preferred for tentative use
in simple cyclitis.
Prognosis. — Cyclitis is more dangerous than simple
iritis, and the prospect of serious permanent injury to the
eye increases with the severity and duration of the attack,
especially with the amount of ciliary tenderness and
hyperemia, and the extent of exudation into the vitreous
as shown by its opacity.
SEQUELS OF IRITIS AND CYCLITIS.
The gravity of iritis is due chiefly to the permanent
lesions caused by it which rise into prominence as the
inflammation of the iris subsides.
Myopia following iritis is observed as soon as the
media become sufficiently clear, after the subsidence of
the inflammation. It continues to diminish, and after
several weeks or months it passes away, the refraction
becoming about the same as it had been previous to the
attack. It may recur with recurrences of the iritis. It
is mostly noticed in eyes previously but slightly myopic
or hyperopic. In eyes highly hyperopic the hyperopia is
commonly temporarily diminished. These changes of
refraction should be met by prolonged use of a mydriatic,
and by the adaptation and proper changes of lenses.
Posterior Synechise. — A few adhesions of the iris
to the lens-capsule may be attended with no serious con-
sequences, particularly if they are slender, and stretch
sufficiently to allow pretty free movement of the iris ; and
are placed outside the limits of the contracted pupil, as
they are apt to be when the pupil has been kept under
the influence of a mydriatic during the height of the
iritis. Such bands tend to become more yielding and
thinner with time, and may cease entirely to interfere
with the movements of the iris.
If, however, a broad unyielding adhesion is located near
the center of the lens-capsule, as it will be if a mydriatic
SEQUELS OF IRITIS AND CYCLITIS. 327
has not been used, it interferes with the entrance of light
through the pupil, and exerts a continuous traction on
both the lens-capsule and the iris. The drag on the cap-
sule affects the curvature of the adjoining portions of the
lens-surface, causing irregular astigmatism ; and disturbs
the nutrition of the part, so that a limited opacity of the
lens results, interfering still farther Avith the light enter-
ing the pupil. The drag on the iris tends to cause
renewed attacks of iritis. These are usually less acute
than the primary attack. But since the iris is bound
down to start with, whatever exudation occurs, tends to
extend its adhesion and cripple it still farther. In this
way the condition of the iris tends from bad to worse,
until one or the other of the graver conditions that are
liable to fellow iritis is brought about.
Various operations for freeing the iris have been devised
and practiced with good results. In the best of these,
the iris is freed from its adhesions, either with a blunt
hook, or by seizing and pulling it with delicate forceps,
corelysis, care being taken to avoid rupture of the lens-
capsule. But operations for posterior synechia are not
often undertaken unless the indications are urgent, and
the adhesions broad and firm ; in which case iridectomy
is the better procedure. Usually such an operation should
be done only when the eye has been for some time quite
free from hyperemia. But indications may arise so
urgent as to justify operation on an acutely inflamed iris.
Occlusion of the Pupil. — In rare cases of plastic
iritis, free deposit of fibrinous exudate from the aqueous
covers the lens-capsule over the whole area of the pupil,
forming a gray membrane ; and partial occlusion is more
common. This membrane remains, permanently occluding
the pupil and greatly interfering with vision. Even a
gray fringe at one side of the pupil may interfere greatly
with vision. Occlusion is to be treated by making an
artificial pupil by iridectomy, when the eye has become
free from signs of irritation.
Exclusion of the Pupil (Annular Posterior
Synechice). — When the whole pupillary margin of the iris
328
EXCLUSION OF THE PUPIL.
FIG. 106.— Ballooning of ftie
iris (after Nettleship).
is bound down to the anterior capsule of the lens, not only
do the effects of broad adhesions occur, but the escape
of fluid from the posterior to the
anterior chamber is interrupted (see
Chapter XV), and other grave con-
ditions arise. The fluid behind it
pushes the iris forward, causing it
to bulge, as in Fig. 106. This is
spoken of as ballooning of the iris
(iris bombe). The iris rises up on
either side of the pupil, usually not
equally all round, but in swellings
separated by depressions where it
is bound down by adhesions. In
the midst of these elevations of
the iris the pupil appears depressed
and is spoken of as crater-like pupiL
With the absence of its normal movements, and under
the pressure to which it is subjected, the iris generally
undergoes atrophy. Its forward displacement at the
periphery is liable to bring it in contact with the cornea,
closing the angle of the anterior chamber and causing
a secondary glaucoma. (See Chapter XV.)
Such an eye, if left to itself, is almost certain to undergo
degenerative changes that will render it hopelessly blind.
Iridectomy should be done upon it as soon as possible,
and repeated, if necessary to establish a free permanent
communication between the anterior and posterior cham-
ber. Iridectomy should be done even though the excluded
pupil be perfectly clear, and the vision still good.
Total posterior synechia is the condition in which
not only the margin of the pupil, but the whole central
posterior surface of the iris, is firmly adherent to the lens-
capsule. It may follow a single severe attack of plastic
iritis untreated with a mydriatic, but commonly it fol-
lows repeated relapses, especially of insidious iritis. It
may cause the \vhole anterior chamber to be shallow.
But there are ho local bulgings like those of " iris
bombe," and the pupil presents no crater-like depres-
SEQUELS OF IRITIS AND CYCLITIS. 329
sion. Rather the iris around the pupil appears thin and
flattened.
In most cases, accompanying changes in the deeper parts
of the eye have caused diminished intra-ocular tension,
and hopeless blindness. When, however, good perception
of light remains, some vision may be preserved ; or
farther degenerative changes in the eyes may be pre-
vented by iridectomy. This, however, must be accom-
panied by removal of the crystalline lens, although it
may still be clear. In total synechia, it is commonly im-
possible to remove any considerable piece of the iris and
make a free opening into the posterior chamber, which is
obliterated except at its periphery, without also removing
the adherent lens-capsule ; and any injury to the capsule
causes such opacity and swelling of the lens, unless it be
promptly removed, as would make the operation very
harmful, rather than beneficial. Extraction of the lens
must be done to render successful the operation of iridec-
tomy.
Atrophy and Degeneration of the Iris. — Pro-
tracted or repeated attacks of iritis, numerous and firm
synechise, exclusion of the pupil and total synechia, are
likely to be succeeded by degenerative changes in the
iris. The surface loses its normal inequalities and luster,
becomes comparatively uniform and dull, and of a gray-
ish color. The iris is thinned, its proper tissue atrophied.
With these, corresponding changes occur in other portions
of the uveal tract ; and such an appearance of the iris is
a most unfavorable sign as to the condition of the deeper
parts of the eye.
Sometimes without general degenerative changes,
atrophy of a particular part of the iris may occur.
Thus after exclusion of the pupil in early childhood,
complete atrophy of certain parts leaves gaps in the iris-
tissue, resembling congenital polycoria. Thinning of the
iris by absorption, until the red fundus-reflex can be
readily seen through it, may occur after the disappearance
of local deposits in the iris, especially after gumma ; or
it may occur after bruising or stretching of the iris, as in
330 DEGENERATION OF THE IRIS.
cataract extraction ; or in elderly people without any
history of previous disease or injury.
NEW GROWTHS IN THE IRIS AND CILIARY BODY.
Gumma of the Iris and Ciliary Body. — In iritis
occurring as a secondary symptom of syphilis there are
often (some writers say always) small temporary papules,
granules, or condylomata, situated near the pupil, which
break down, sometimes giving rise to visible debris in
the anterior chamber. In the tertiary stage gummata in
the form of large rounded masses, like those shown in
Fig. 107, appear in the iris, with severe iritis. These
undergo absorption under treatment for syphilis, leaving
distinct scars in ^the iris. Gumma arising in the ciliary
body is attended with cyclitis, and may cause marked dis-
placement of the iris, or staphyloma of the ciliary region
and corneal astigmatism. It should receive the same
treatment as gumma elsewhere, except that mercury is
relatively more important than potassium iodid.
Tuberculosis of the iris occurs before the age of
twenty. It begins as isolated nodules in the iris-tissue,
each surrounded by minute vessels. The iris is swollen
and inflamed throughout. The general appearance is
illustrated by Fig. 108. The individual deposits may
FIG. 107.— Gumma of the iris, the FIG. 108.— Tuberculosis of the iris,
new growths seen as rounded prom- the tubercles showing as small light
inences of lighter color, below the prominences. Some pericorneal ny-
pupil. peremia.
continue to grow until several millimeters in diameter;
or they may undergo absorption, and be followed by a
fresh crop. Occasionally but a single growth appears
(granuloma of the iris), which may increase in size and
TUMORS OF IRIS AND CILIARY BODY, 331
destroy the eye. In rare cases the growths finally dis-
appear leaving the eye with good sight and the patient
free from tubercular lesions. Mostly the eye is destroyed,
and the patient succumbs to general tuberculosis. The
treatment is the general treatment for tuberculosis and
iritis.
Sarcoma of the Iris or Ciliary Body. — Sarcoma
in the iris starts as a single brown mass which at first
grows very slowly, If not much pigmented, vessels may
be traced upon it. Frequent hemorrhage may occur.
If it starts behind the iris, it becomes adherent to it;
and, carrying it away from its ciliary attachment, causes
an iridodialysis. It is most common in early adult life,
but may occur at any period. After a period of slow
growth which may last for years, sarcoma causes inflam-
mation and increased tension of the eyeball, breaks
through the sclero-corneal coat, and terminates in a
rapidly growing tumor and death. In a few cases the
growth has been removed with the segment of the iris
from which it springs, and has not recurred. More fre-
quently the whole eyeball must be excised, or if it has
penetrated the sclera the whole contents of the orbit
should be removed, as for sarcoma of the choroid.
Carcinoma of the iris or ciliary body is very rare.
Benign Tumors.— A congenital projection of the
uveal layer of the iris forward through the pupil, such as
FIG. 109.— Cyst of the iris occupying the lower outer part of the anterior
chamber.
is normal in the eye of the horse, is called ectrojoion of the
uvea. It appears as one or more chocolate-brown nodules
on the pupillary margin.
Minute benign pigmented growths, melanomata, some-
332 BENIGN TUMORS.
times occur in the iris. Cyst of the iris is a gray round
translucent tumor having much the appearance repre-
sented in Fig. 109. It consists of a thin transparent wall,
containing a serous fluid. An epidermoid pearl or pearl-
cyst of the iris is a small white slowly-growing mass of
epithelial or atheromatous material. Both cysts and
epidermoids disturb and injure adjoining tissues by press-
ure, and if undisturbed may cause glaucoma. They
commonly start from some injury, especially the implan-
tation upon the iris of a cilium, or a piece of epithelium
from the skin or conjunctiva. They should be excised.
A few cases of vascular tumor of the iris are recorded.
MOTOR DISORDERS OF THE IRIS AND CILIARY
MUSCLE.
The normal reactions of the pupil and their alterations
by disease have already been described (page 72), and are
further referred to in Chapter XX. Persistent dilatation
of the pupil from whatever cause, is called mydriasis.
The most frequent cause of mydriasis is the use of a
mydriatic. It may be placed in the patient's eye without
his knowledge, as by a contaminated dropper ; or he may
use it and deny it. The amount required to produce
mydriasis is so minute that it may be splashed into the
eye, causing unilateral mydriasis ; or taken in medicine
or food quite unconsciously, when it will cause equal
dilatation of both pupils.
Persistent contraction of the pupil is called myosis.
It may also be caused by drugs, especially eserin (physos-
tigmin) or pilocarpin locally, and opium internally.
Various conditions of the iris, especially moderate hyper-
emia, also cause it. Exaggeration of the normal alternat-
ing contraction and dilatation of the pupil on passing
from a dim to a bright light is hippus. Tremulousness
of the iris, when the iris loses the support of the crystal-
line lens, is called iridodonexi*.
Cycloplegia, paralysis, or paresis of accommodation,
paralysis, or paresis of the ciliary muscle, is to be sharply
distinguished from presbyopia, although their symptoms
IRIS AND CILIARY MUSCLE. 333
are in some respects precisely alike. The former is loss
of power in the muscle, an inability to influence the still
flexible lens, a true paralysis or paresis. The latter arises
from increased resistance of the lens, limiting the effect
produced upon it by the normal ciliary muscle. Pres-
byopia comes on imperceptibly, and rarely or never
diminishes. Paralysis of accommodation may be entirely
sudden ; even when most gradual it changes notably from
month to month ; and it may end in partial or complete
recovery. One or both eyes may be affected.
Causes and Varieties. — The most frequent cause is
the influence of a cycloplegic drug, which, at the same
time, produces dilatation of the pupil. Diphtheritic par-
alysis of the accommodation comes on at the third to the
sixth week from the onset of the disease, and lasts from
a few days to six months. It is commonly not attended
with dilatation of the pupil. It is sometimes complete,
but more frequently partial. Similar weakness of accom-
modation may follow epidemic influenza, "grip," and
other acute diseases. Paralysis of the ciliary muscle
may also attend degenerative changes in the brain and
spinal cord. It may be caused by nasal disease.
Spasm of the ciliary muscle, or spasm of accom-
modation, has been already alluded to (pages 129 and 149).
It also is produced by drugs, eserin (physostigmin) and
pilocarpin, and by disease of the central nervous system.
The treatment is the use of a mydriatic, and the removal
of the cause, if possible.
SYMPATHETIC OPHTHALMIA.
When, after injury, an eye is permanently damaged by
plastic inflammation of the uveal tract, the fellow eye is
liable to suffer from what is called sympathetic disease.
Cases apparently similar occur in which the first eye is
diseased without traumatism ; but these may be instances
of bilateral idiopathic disease, one eye being affected
before the other. Sympathetic involvement of the
second eye has been recognized for two hundred years.
334 SYMPATHETIC OPHTHALMIA.
Donders pointed out that there were two separate dis-
eases, one marked by great liability to complete destruction
of sight, and but slightly influenced by treatment, sym-
pathetic inflammation; the other causing great temporary
interference with vision, but promptly cured by removal
of the injured eye, sympathetic irritation. Obscure sym-
pathetic amblyopia may also occur. The wounded one is
called the exciting eye • the other the sympathizing eye.
Sympathetic Inflammation (Sympathetic Ophthal-
mitis, Cyclitis or Iridocyclitis, Uveitis Maligna, Migratory
Ophthalmia). — Sympathetic ophthalmitis is a general in-
flammation of one eye, following injury to the other eye,
and characterized by an insidious invasion, severe inflam-
mation of the uveal tract, a chronic course, with strong
tendency to repeated relapses and exacerbations, and end-
ing often in complete blindness.
Symptoms and. Course. — Sympathetic disease rarely
or never begins until two or three weeks after the injury
of the exciting eye. It most frequently occurs at from
six to ten weeks ; and after two years from the primary
injury it is extremely rare. The first symptom may be
inability to sustain an effort of accommodation in the
sympathizing eye. This is usually followed by hyperemia
of the whole eye, at first slight, but gradually increasing.
In a few cases, there has been early optic neuritis, and
neuroretinitis. In other cases, the first hyperemia is
mainly conjunctival. In all cases, however, there soon
appear discoloration of the iris, pericorneal redness, pain,
photophobia, specks of exudate on the posterior surface
of the cornea (keratitis punctata), plastic exudation bind-
ing the iris to the anterior capsule ; and clouding of the
vitreous humor. These symptoms increase in severity
until vision is greatly impaired. Under treatment, or
possibly without it, they may then greatly improve. But
usually there is a relapse, the plastic exudation increases,
the vitreous becomes more clouded, and vision still further
reduced.
If the case is going on to partial or complete recovery,
the relapse will be less severe than the original attack ;
SYMPATHETIC OPHTHALMIA. 335
»
and probably after one or two relapses there will be con-
tinued improvement. If the case passes toward an un-
favorable termination, each relapse leaves the eye more
damaged ; and relapses continue to occur at intervals of a
few weeks to many months, until all vision is lost, and
the eyeball shrunken and soft. Commonly, diminished
tension may be noticed within a few days after the com-
mencement of the inflammation of the uveal tract. The
pain at first is rather slight, and the iris may be firmly
bound down before it is realized that the inflammation is
at all serious. Subsequently the pain and dread of use
of the eyes, or of exposure to light, become more
marked.
Opacity of the vitreous usually interferes with the
study of the ophthalmoscopic changes, but alterations of
the choroid are the rule, while much inflammation of the
optic nerve and retina are believed to be exceptional.
Occasionally, there is severe inflammation of the cornea
and conjunctiva, the latter without any great amount of
discharge. Cases have been reported as of sympathetic
origin, where the inflammation was confined to the cornea
and conjunctiva. But it is doubtful if these should be
regarded as instances of sympathetic disease.
Causes and Pathology. — The only well understood
element in the causation of this disease is the injury to
the exciting eye. This injury may possibly, in some
cases, be a simple plastic inflammation of the uveal tract
of that eye. But in the great majority of cases it is a
plastic inflammation following perforation of the coats,
occasionally following perforation by ulceration, as in
intra-ocular tumor, usually following perforation by trau-
matism. When to traumatism is added the lodgement
of a foreign body inside of the vitreous chamber, the risk
of sympathetic inflammation is greatly increased. The
removal of such a foreign body, after plastic inflamma-
tion has been set up, does not remove all chance of
sympathetic disease, but does diminish the probability of
its occurrence. Penetrating wounds of the ciliary region
have been noticed to be especially likely to cause this
336 CAUSES AND PATHOLOGY.
disease. Wounds penetrating through the cornea, an-
terior chamber and iris are decidedly less likely to cause
it. It more frequently occurs in children and young
persons than in later life.
How the disease of the exciting eye sets up the disease
in the other is not known. But the speculations regard-
ing it are of interest for their bearings on general
pathology. The optic nerves connected by the chiasm,
and the lymph-channels immediately around them, have
been regarded as the path by which an infection " mi-
grated " from the one eye to the other. But there is little
microscopical or experimental evidence to support this.
Experiments made to confirm it have nearly all failed to
produce any inflammation of the second eye. And where
such inflammation was produced, it was probably part of a
general infection rather than a genuine sympathetic oph-
thalmitis. It has been supposed that the ciliary nerves
were the channels through which the exciting eye in-
juriously aifected the sympathizing eye ; but here too,
positive evidence is lacking. Sometimes changes have
been found in these nerves, sometimes they have not;
and if the influence of the nerves be one of perverted func-
tion, marked histologic changes in them should not be
expected. It has been suggested that some morbid
material from the exciting eye may enter the blood and
set up inflammation in the uveal tract of the sympathizing
eye, although doing no harm in other parts of the body.
This might be a cytotoxin developed from cells of the
uveal tract (Brown Pusey); although such an occurrence
seems at variance with the law that no organism develops
toxins destructive to its own cells.
Finally, it is suggested that through the ciliary nerves
the injured eye is capable of unfavorably influencing its
fellow, so that the influences tending to excite inflamma-
tion therein, which would otherwise be successfully resisted,
are able by aid of this morbid predisposition, to overcome
the resistance of the tissues; and that a sympathetic
inflammation is set up by the injurious substances from
the exciting eye, or the ordinary causes of inflam-
SYMPATHETIC OPHTHALMIA. 337
raation acting in the presence of this constant unfavor-
able influence exerted by the injured eye.
Diagnosis. — When one eye has been lost or seriously
impaired, any inflammation in the second eye should
excite suspicion. The careful examination of the pre-
'viously blind eye will then indicate if it be liable to cause
sympathetic disease. If it be blind with diminished ten-
sion, adherent and degenerated iris, and opacity prevent-
ing any view of the fundus, especially with any history
of injury, it must be regarded with grave suspicion. In
the supposed sympathizing eye the presence of the signs
of iridocyclitis point to sympathetic inflammation. With-
out these the diagnosis cannot be certainly made.
Even though the disease be sympathetic, one must still
distinguish between inflammation and irritation. Sympa-
thetic inflammation comes on usually within a few weeks or
a few months after injury. Or if it arises later, it mostly
follows a renewal of the inflammation in the exciting eye.
Irritation usually occurs years after the exciting eye has
been injured, and has long been free from inflammation,
and its tissues have undergone degeneration, especially
if it be the seat of calcareous changes, or ossification of
the choroid.
Sympathetic irritation may be attended with great
irritability of the sympathizing eye, increased lacrima-
tion, fear of light and complete inability to use the eye.
But on examination it will be found that the pupil reacts
freely to light, and that the iris is of normal appearance ;
and on removal of the cause of irritation, complete re-
covery occurs within a few hours or days. The earliest
symptoms of sympathetic inflammation may, however,
closely resemble those of sympathetic irritation. In both
cases it may be difficult to use the accommodation.
Treatment. — The fact that the exciting eye has already
been greatly damaged or destroyed, and that after the
actual involvement of the sympathizing eye the most
efficient treatment may fail to save it, makes prophylactic
treatment of the highest importance. This consists in
22
338 PROPHYLACTIC TREATMENT.
the removal of what is liable to become an " exciting
eye." On this account the eyeball should be removed :
A. If blind from injury and the seat of iridoeycKtis.
(1). When known or supposed to contain a foreign body
which cannot be extracted. (2). When the injury has
occurred in the ciliary region. (3). If the injury be recent
(within two years) and the patient cannot remain within
easy reach of competent professional advice, even though
the eye does not contain a foreign body, and the wound
was not in the ciliary region.
B. If not blind, but with greatly impaired vision and the
seat of iridocyclitis. (1). If known to contain a foreign
body that cannot otherwise be removed. (2). If the
wound be in the ciliary region, and the inflammatory
process be active with diminished intra-ocular tension.
C. If the eye has been so severely injured that all
chance of further useful vision is destroyed, even though
inflammation has not yet set in, it should be removed if
the patient cannot remain under competent observation.
The operations of enucleation of the eyeball and its sub-
stitutes are described in Chapter XIX. Their value in pre-
venting sympathetic ophthalmitis may be considered here.
It cannot be claimed that evisceration, with or without the
insertion of an artificial vitreous, has been practiced long
enough or widely enough to prove that it is equal in
value to enucleation ; but it has been sufficiently practised
to show that it has value in this direction. If infection
travelling through the optic nerve, or by the lymph-chan-
nels adjoining it, be a factor in producing sympathetic
ophthalmitis, evisceration must always be inferior to
enucleation as a prophylactic measure, for infection
already lodged in the sclera or adjoining lymph-spaces
would be undisturbed by evisceration, but would be thor-
oughly removed by enucleation. Besides the removal of
the injured eye, the only measures of prophylaxis are
those of general hygiene, and care in the use of the eyes.
When sympathetic inflammation has already begun, we
must first consider the value of the exciting eye. In a
few cases this retains useful vision ; and, singularly
SYMPATHETIC OPHTHALMIA. 339
enough, may still continue with useful vision, although
the sympathizing eye may be entirely lost. In such cases
the exciting eye will be in the end the only seeing eye
and must therefore be retained. But if the sight of the
exciting eye be already lost, or if it is the seat of active
inflammation that is likely to destroy its sight, it should
be removed at the earliest possible moment. Years ago
the opposite advice of a few authorities left the surgeon
in uncertainty as to what he should do. But the experi-
ence of the profession has now demonstrated that the
chance of recovery of the sympathizing eye, is much
better if the exciting eye be promptly removed.
The adaptation of an artificial eye to replace the globe
removed is discussed in Chapter XIX.
The patient should be confined to a darkened room,
spending must of the time in bed, but allowed to move
about sufficiently to avoid bed-weariness. The eye must
have complete rest and should be kept fully under the
influence of atropin, unless iritic adhesions have already
become so extensive and firm that the drug can cause but
little or no retraction of the iris. Leeches, or the artifi-
cial leech, may with advantage be applied to the temple
daily for a few days during the height of the attack.
Bathing the eye for a few minutes in very hot water
may be practised every few hours.
The general treatment should include the use of mer-
cury ; up to, but not beyond, the point of constitutional
impression. This may be given in laxative doses of
calomel, and inunctions, until some effect is produced ;
and then its action sustained by the internal use of the
protiodid or bichlorid. In addition, tincture of the
chlorid of iron in large doses has appeared beneficial ; and
small doses of quinin are usually indicated. Equal in
importance with such specific medication is care to im-
prove in every way the general health and nutrition of
the patient. If pain prevents sleep, small doses of
morphin or acetanilid may be given each evening.
After the inflammation has subsided, it is sometimes
necessary to do iridectomy or some allied operation, to
340 TREATMENT.
make a clear passage where the pupil has been closed by
the attacks of inflammation. Such operations are diffi-
cult on account of the inelastic brittle condition of the
iris, and are very liable to be followed by a renewal of
inflammation. They are best postponed until many
months, or even years, after all symptoms of inflammation
have subsided.
Prognosis. — The majority of cases of sympathetic
ophthalmitis end in blindness. Probably half of those
energetically and intelligently treated from early in the
disease, do not escape this fate ; and it is certain in all
neglected cases. Even when the disease seems to yield
promptly to treatment, the prognosis must be carefully
guarded. The special tendency to relapse must be in-
sisted on ; and where the eye has been already consider-
ably damaged tHe danger of relapse and further impair-
ment will not be over for two years. When, however,
the relapses become less and less severe, and the eye on
the whole is improving, the outlook is encouraging ; and
if the recovery from the earlier attack is complete, and
has lasted for one year, the eye may be regarded as
cured.
It is to be borne in mind that even after the removal
of an injured eye the danger of sympathetic inflamma-
tion continues for at least three or four weeks. In
numerous cases it has appeared two or three weeks after
the removal of the exciting eye ; and has run a character-
istic course, though generally such attacks have been mild
and amenable to treatment.
Sympathetic Irritation (Sympathetic Neurosis).—
This condition, long confused with sympathetic inflamma-
tion, is one in which the sympathizing eye may be ren-
dered entirely useless, temporarily, or so long as the
exciting eye is retained ; yet on removal of the exciting
eye, recovery is complete within a few hours or days.
Symptoms and Course. — Sometimes during the first
few days after injury to the eye, and before it is time for
sympathetic inflammation to develop, the other eye may
appear disturbed, very sensitive to light and irritable
SYMPATHETIC OPHTHALMIA. 341
when used. But this primary disturbance quickly sub-
sides and many months or years elapse before true sym-
pathetic irritation is likely to be developed. It begins
with difficulty or pain in using the eyes for near work.
If the accommodation be not actually diminished in
amount, the ciliary muscle is quickly tired ; and blurring
of near-vision, or pain, occurs after the eyes have been used
but a short time. Soon photophobia and excessive lacrima-
tion develop; then general hyperemia of the conjunctiva and
sclera. These symptoms may yield to rest of the eyes,
or improve spontaneously. Later they recur, grow worse,
and become more constant. Examination of the eye
becomes difficult, but the pupil dilates fully, and by using
cocain, the media and fundus of the eye can be seen to be
normal. In sympathetic amblyopia, the impairment of
vision is more gradual and constant, and the photophobia,
lacrimatiou, and hyperemia, slight or entirely absent.
The diagnosis has been discussed in connection with
that of Sympathetic Inflammation (page 337). It may
also be needful to distinguish these conditions from
hysteria, malingering (where damages are involved), and
the dread of blindness, which sometimes greatly disturbs
patients who have lost an eye by injury.
Treatment and Prognosis. — The removal of the ex-
citing eye is the only treatment and the whole treatment.
Perfect cure can be promised from it. If this is not
removed, the disability of the sympathizing eye will
remain, partial or complete, under any other treatment.
For the relief of sympathetic irritation evisceration is
equally as effective as enucleation. Even optico-ciliary
neurotomy will give at least temporary relief.
DISEASES OF THE CHOROID.
Purulent Choroiditis (Suppurative Choroiditis or
Irido-choroiditis, Panophthalmitis). — Purulent inflam-
mation of the choroid is rarely or never confined to
that membrane. Not only does the whole uveal tract
participate in the process, but the retina and vitreous are
involved and usually the whole eyeball, and sometimes
adjoining structures suffer with it.
342 PURULENT CHOROIDITIS.
Causes. — Direct infections by perforating wound of
the eyeball, septic operations, especially cataract extrac-
tion or needling, or suppurating ulcer of the cornea, are
the common causes of choroidal suppuration. It may also
arise from suppuration or thrombosis in the orbit. From
these causes it attacks only the one eye. It also occurs,
generally affecting both eyes, from metastasis or embolism,
in erysipelas, puerperal sepsis, septic endocarditis and
other forms of pyemia, scarlet fever, cerebrospinal menin-
gitis, influenza, and other acute specific diseases.
Symptoms and Course. — The attack is usually very
severe. The exceptions to this occur late in the course of
exhausting febrile disease, and with cerebrospinal menin-
gitis in young children. There is severe pain in the eye
and head, intense iiyperemia of the whole eye and its ap-
pendages ; swelling of the conjunctiva with chemosis ;
sudden swelling of the lids; and sometimes such swelling
of the orbital tissues as to cause marked protrusion of the
eyeball. There is great tenderness. There may be a dis-
tinct rigor ; and rapid elevation of the bodily temperature,
with the general symptoms of pyrexia, including
delirium.
The vitreous and often the anterior media quickly
become so hazy that nothing can be seen through them,
and hypopyon may form. In most cases the sclero-
corneal coat is perforated so as to permit the free escape
of pus before any marked amelioration of symptoms
occurs. The pain then diminishes, the eyeball becomes
soft, shrinks, and phthisis bulbi results ; the eye, after
many weeks, or even months, becoming quiet, and free
from hyperemia or pain.
Where the disease arises in connection with the specific
fevers, it is apt to run a less violent course. Great pain
and swelling may be absent. The vitreous becomes
opaque, and appears yellow by focal illumination. Hypo-
pyon may be noticed ; but there occurs no perforation of
of the sclero-corneal coat. The tension of the eyeball, at
first rather elevated, falls below the normal, the hyperemia
and tenderness slowly disappear, and after many weeks,
DISEASES OF THE CHOROID. 343
the eye is found soft, with more or less opacity of the
vitreous, and discoloration and degeneration of the iris.
The purulent accumulation in the vitreous is often desig-
nated pseudo-glioma. Its differentiation from glioma of
the retina is important. It is given in connection with
that affection.
In a few cases, usually in young children, after cerebro-
spinal meningitis (the author has also seen it after typhoid
fever), some sight remains in the eye, and slowly improves
with the diminution of the vitreous opacity, which con-
tinues for many months, or even years afterward.
Diagnosis. — Purulent choroditis is only liable to be
overlooked when it supervenes upon severe inflammation
of the eye, as suppuration of the cornea or the orbit, or
in erysipelas of the lids; or when, in connection with
exhausting general disease, the onset is insidious and the
patient so ill as not to call attention to the loss of sight.
It is liable to be mistaken for orbital cellulitis, in which,
however, the dioptric media remain clear; or confused with
acute glaucoma, which can be known by the dilated pupil,
the absence of history of any cause for choroidal suppu-
ration, and the lighter swelling of the conjunctiva and
neighboring parts.
Treatment. — This is to be directed mostly to relieving
pain and shortening the course of the disease. If the
patient will consent to it, these indications will be most
promptly and effectively met by at once enucleating the
eyeball. Enucleation during panophthalmitis has been
credited with causing meningitis and death. Numerous
cases have been reported in which death by meningitis
followed the enucleation of suppurating eyeballs. But in
some of these cases it is evident that the meningitis had
begun before the enucleation, and in others it is probable
that it would have occurred without enucleation, as it has
done sometimes when enucleation was not practiced. The
author believes that the patient's risk of meningitis is not
increased by enucleation if the operation is a surgically
clean one, sufficient bleeding is allowed, and perfectly free
drainage of the orbital tissues is secured. The former
344 TREATMENT OF PANOPHTHALMITIS.
practice of at once stopping the bleeding that follows
enucleation, by packing the orbit, and keeping it for hours
under firm pressure, was far more likely to have caused
meningitis than* the enucleation.
If the patient refuses enucleation, or his general con-
dition prevents it, the eye may be poulticed ; and at the
end of two or three days freely incised through the cornea,
to allow the escape of the crystalline lens and the puru-
lent accumulations behind it. Pain may be lessened by
free leeching from the temple ; and opium and acetanilid
given internally. A free laxative may be given, and
afterwards the tincture of chlorid of iron, and quinin,
with such other treatment as the patient's general con-
dition demands.
The few cases *n which any vision is retained should
be treated without poulticing or incisions, commonly with
prolonged rest of the eyes under a mydriatic. Especial
attention should be given to everything calculated to build
up the general health.
Prognosis. — Severe panophthalmitis always ends in
blindness, generally with shrinking of the eyeball. But
an eye thus lost is not likely to excite sympathetic inflam-
mation. In pseudo-glioma there is no chance of restoring
sight. In the few cases that retain some vision, slow
improvement may continue for one or two years, and very
useful although not perfect sight may be ultimately
obtained.
Plastic Inflammation and Atrophy of the
Choroid. — Under this head are included all non-puru-
lent inflammations of the choroid. Although to some of
these conditions the term plastic inflammation may appear
not to be strictly applicable, they all show a strong ten-
dency to produce permanent visible alterations of structure
through the organization of exudates. Such alterations
commonly include both the formation of cicatricial con-
nective tissue, and the atrophy to a greater or lesser extent
of normal choroidal structures. Hence the necessity of
considering them as two parts of a single process.
Causes. — The choroid is liable to be involved in all
DISEASES OF THE CHOROID. 345
kinds of inflammation of the iris and ciliary body, so that
all causes for those inflammations are causes of choroiditis.
Plastic choroiditis and atrophy also arise without iritis or
cyclitis, from eye-strain, especially in progressive myopia ;
from syphilis ; from obscure disorders of general nutrition
attended with anemia, in connection with menstrual
derangements ; and from traumatism. It has been sup-
posed that choroidal atrophy occurred without inflamma-
tion from mere stretching of the choroid in high myopia ;
but this is not certain.
Symptoms and Course. — The characteristic symptoms
of plastic inflammation of the choroid can only be studied
with the ophthalmoscope. The acute stages attended with
hyperemia may present flashes of light that occur at short
intervals when the patient is in comparative darkness.
The retina in contact with the affected area may suffer, so
as to cause impaired vision, and a sense of a cloud before
the sight (positive scotoma). But if the affected area is
away from the macula, this impairment of vision will
readily passed unnoticed. Accompanying opacities of the
vitreous or lens may also impair vision. Sometimes great
atrophy of the choroid occurs without much impairment
of vision ; and the choroidal changes may be far advanced
before any opacity can be seen in the vitreous or lens.
The process may be entirely painless, or there may be a
dull aching referred to the eyes and frontal region. In
the absence of iritis and cyclitis, the eye externally
presents a normal appearance ; or in exceptional cases
there is a slight hyperemia of the deep scleral vessels.
With the ophthalmoscope we cannot directly recognize
general hyperemia of the choroid ; but it is attended with
heightened color of the optic disk, the capillary vessels
of which spring from the same source as the choroidal
vessels, and not from the central retinal vessels. The
early stage of choroiditis causes a lighter yellowish color
of the fundus, with blurring of the choroidal details if
these are visible. This blurring if general may cause a
more uniform scarlet color; if confined to certain portions
it causes blotches of the lighter, yellower red. A slight
346 SYMPTOMS OF CHOROIDITIS.
choroidal inflammation is apt to cause absorption of the
layer of pigment-cells that overlie it, the retinal pigment-
layer. If this layer be generally absorbed, the choroidal
vessels are visible, as in Fig. 118, and the upper and
lower part of Fig. 110. If the retinal pigment-layer be
thinned or lacking in scattered areas, it gives the fundus
a " patchy " appearance.
Acute plastic choroiditis may give rise to well-marked
localized swellings over which the retinal vessels may be
seen to pass, or the affected area may be partly or wholly
hidden by a diffuse haziness of the vitreous in front of it.
After a few days or a few weeks, the swelling disappears
and the choroid in the affected area becomes thinned.
This may leave the larger choroidal vessels, which lie in
its deeper layerf uncovered, and abnormally prominent,
or it may include these so that the affected area shows
the white solera.
The earliest stages of choroiditis show no pigment-
changes, but as the case progresses toward atrophy these
always occur. The margin of the affected area always
showrs specks and blotches of dark-brown or black pig-
ment-masses ; and similar deposits occur within the atro-
phic area. Such deposits may be noticeable within two
weeks of the onset of acute choroiditis ; but they may
continue to increase and alter for many months. Finally
they seem to reach a permanent condition, and remain
with atrophy throughout life, a visible record of previous
disease. Their appearance is illustrated in Fig. 110.
Opacities in the vitreous and crystalline lens may also
remain as evidence of a previous choroiditis.
Varieties.^ J/2/opt'c choroiditis has already been de-
scribed in connection with myopia (page 160). Dixxnni-
natcd choroiditis is characterized by distribution of the
choroidal changes in scattered areas, the intermediate
fundus being comparatively normal as in Fig. 110.
One or two such areas, the remainder of the choroid
being healthy, constitute a localized choroiditis. A
single area occurring at the macula is called a central
choroiditis. In this position the scotoma it causes is sure
DISEASES OF THE CHOROfD. 347
to attract attention; and even comparatively slight
changes will be noticed on that account. A form of
central choroiditis occurring in old people, called there-
fore senile choroiditis, may be a cause of poor vision and
disappointment after cataract extraction. In anterior
choroiditis the lesions are confined to the anterior portion
FIG. 110. — Disseminated choroiditis. Patches of choroidal atrophy scattered
over the fundus. The macula has escaped damage. A partial atrophy near
the left upper corner exposes the choroidal vessels.
of the choroid. Sometimes they are so far forward as to
be out of sight with the ophthalmoscope ; and their ex-
istence can only be guessed from the presence of opacities
in the anterior portion of the vitreous.
Diffuse choroiditis invades one or a few large areas of
the fundus. The exudate is usually extensive, and slowly
gives place to atrophy. Marked pigment-changes may
be noted while yet the yellowish color of the exudate
forms the background for the pigment-markings.
Diagnosis. — Choroidal inflammation and atrophy must
348 DIAGNOSIS OF CIIOROIDITIS.
be distinguished from retinitis, by the fact that the retinal
vessels are not altered in size or outline, and are not hid-
den or partially obscured in certain parts of their course.
This will also distinguish choroidal atrophy from other
retinal conditions as opaque nerve-sheaths, fatty degene-
ration, etc. It must, however, be remembered in con-
nection with choroiditis that diffuse haziness of the
vitreous may so veil the retinal vessels as to simulate
retinitis ; and that not rarely both retina and choroid are
involved in the same inflammation (see page 101). Atrophy
of the choroid must also be distinguished from coloboma.
This is most difficult as between the rounded partial
colobomas that occur in the macula and elsewhere, and
isolated patches of choroidal atrophy. The black pig-
ment-deposits i« the choroid may be confused with opa-
cities in the vitreous or lens. Compare Figs. 63 and 110
with Figs. 115, 116, 117, and 118. Patches of anomalous
pigmentation may readily be taken for patches of choroid-
itis. (See page 99.)
Treatment. — For choroiditis the eyes should, as far as
possible, be put at rest, usually under the full influence
of a mydriatic. They should constantly wear correcting
glasses. In acute cases the patient may be kept for a few
days in a darkened room, with little active exertion ; and
local bleeding from the temple may be practiced on suc-
cessive days. Exposure to excessive light and sudden
changes of light must be avoided, dark glasses which are
large enough, and fit so as to protect the eyes thoroughly,
should be worn out of doors. The eyes must also be
guarded from radiant heat as from a stove, open fire, or
lighted lamp.
Alteratives, especially mercury and potassium iodid arc
commonly given for a considerable time. If syphilis is
probable, the former should be used freely by inunction,
until its constitutional effects begin to manifest them-
selves. Subconjunctival injections of mercuric chlorid
have been advocated as of marked value. Any other
probable cause or underlying dyscrasia should receive
appropriate treatment. But often none can be discovered.
DISEASES OF THE CHOROID. 349
It is then of the highest importance in all cases to im-
prove the general condition of the patient. On this
account confinement to a dark room should be resorted to
only in the acute cases, and with them limited to a very
few days. In chronic cases, the patient should live as
much as possible in the open air, and often a change of
occupation or residence will be of benefit.
Prognosis. — Choroiditis is always a very serious dis-
ease. Sight lost through it is never perfectly restored ;
and so long as it is active, or recurs involving new areas,
every eifort should be made to limit its ravages. Local-
ized choroiditis due to eye-strain is most amenable to
treatment ; and next to this, choroiditis due to syphilis ;
these being the varieties whose etiology is best under-
stood.
Choroidal hemorrhage is rare as compared with
retinal hemorrhage. If deep and diffused, it may merely
cause a deeper red of the affected portion of the fundus ;
if more superficial, it cannot be distinguished from hemor-
rhage in the deep layers of the retina, except that it
has not the very dark red color sometimes presented by
retinal hemorrhage. From hemorrhage into the nerve-
fiber layer of the retina, it is distinguished by its rounded
outlines as contrasted with the "flame shape" of the
retinal hemorrhage. The choroidal vessels are the most
frequent source of hemorrhage into the vitreous. The
treatment is merely that of the associated conditions.
Detachment of the choroid from the sclera is
sometimes found in dissecting degenerated eyeballs, but
is very rarely seen with the ophthalmoscope. So seen, it
cannot be distinguished from detachment of the retina,
unless the choroidal vessels are visible, in which case it
resembles sarcoma of the choroid.
Colloid masses may form in the choroid in elderly
people, causing rounded whitish spots, which may be
massed together at the macula, or scattered over the
fundus. They do not necessarily impair vision.
Ossification of the Choroid. — In eyes long blind
and degenerated, calcareous change is often found in the
350 OSSIFICATION OF THE CHOROID.
choroid ; and sometimes the choroid is replaced by true
osseous tissue. If the ossification be sufficiently extensive,
it may be detected by pressure upon the globe through
the closed lids. It may become an indication for removal
of the eye, by causing sympathetic irritation.
Shrinking of the eyeball is apt to follow extensive
plastic disease of the uveal tract. With the contraction
and organization of the exudate, which forms a mass be-
hind the lens, the retina is detached from the choroid,
and drawn with the shrunken vitreous into a chord,
stretching from the optic nerve to the posterior pole of
the lens. The lens is often shrunken and pushed forward,
the anterior chamber appears shallow, and the cornea
smaller than normal. The eyeball is softened, so that the
pressure of the four recti muscles causes it to assume a
somewhat quadrate form. This condition comes on
slowly, sometimes after repeated attacks of inflammation,
sometimes after a single severe attack. When suppura-
tion of the uveal tract goes on to perforation of the sclero-
corneal coat the shrinking is more irregular, much more
rapid, and the resulting stump smaller, with less resem-
blance to a normal eye. Fuchs calls the former condition
atrophy of the eyeball, the latter phthisis bulbi. Other
writers use these terms interchangeably. The former
condition is attended with greater danger of sympathetic
inflammation, and therefore is an indication for enuclea-
tion. The latter may permit of the wearing of an arti-
ficial eye over the stump. Either, after many years, may
cause sympathetic irritation.
TUMORS OF THE CHOROID.
Sarcoma of the choroid occurs about once in 3000
cases of eye-disease, mostly about middle age. It starts
usually as a rounded lobulated tumor in the fundus of the
eye, distinguished from detachment of the retina by the
vessels which may be seen lying beneath the retina. Its
appearance is illustrated in Fig. 111.
The growth causes blindness of the overlying retina,
DISEASES OF THE CHOROlD. 351
and a corresponding defect in the field of vision. But if
it does not involve the region of the macula, it may grow
a long time without attracting the patient's attention, and
without any alteration of the external appearance of the
eye, or other symptoms. Hence this is called the latent
stage of the disease. It often lasts for years.
Later the eye begins to show evidences of deep inflam-
mation, and the tension of the globe is increased. This
is called the inflammatory or glaucomatous stage. The an-
FIG. 111.— Sarcoma of the ehoroid in the right eye, starting to the temporal
side of the macula; first stage. The rounded masses of the growth are seen on
the left, containing vessels that look like choroidal vessels, and with the finer
retinal vessels running over them.
terior chamber is shallow, the eye painful ; and it may be
very difficult to make the diagnosis between this condi-
tion and ordinary glaucoma. After a time, varying from
a few weeks to many months, the growth penetrates the
sclera, the tension of the eyeball falls, and the pain
abates. If the perforation be far enough forward, the
tumor-mass is at once seen springing from it, but if out
352 SARCOMA OF THE CHOROID.
of sight, the case may still remain obscure. In this third
stage its growth is rapid and soon causes the appearance
of a large tumor in the orbit. The fourth or final stage
begins with the involvement of other portions of the
body by metastasis. The case ends in death from rapid
exhaustion or the overwhelming of some vital organ.
Diagnosis. — Sarcoma of the choroid is distinguished
from glioma of the retina by the age of the patient.
Sarcoma is extremely rare in childhold ; glioma occurs
only before the age of twelve years. From simple
detachment of the retina it is distinguished by its reddish
yellow color, the seeing of vessels beneath the retina, the
absence in most cases of movement of the retina, floating
on a serous fluid, and by transillumination (p. 77). The
latter is of v§lue chiefly for tumors anterior to the
equator of the eyeball. Ophthalmoscopic examination,
using direct sunlight, may reveal the tumor through the
detached retina. The distinction from primary glaucoma
is given in connection with that disease (Chapter XV).
When the tumor has perforated the sclera, its character
may be recognized by the microscope ; or, usually, by its
abundant pigmentation.
Treatment. — This is the earliest possible removal of
the eyeball ; or if the sclera is already perforated, the
removal of the whole contents of the orbit. When the
growth cannot wholly be removed, the treatment with
the mixed toxins of erysipelas and bacillus prodigiosis
(Coley's method) offers a small chance of cure. If the
growth of the tumor cannot be checked, it should be kept
well cleansed and disinfected.
Prognosis. — The spindle-cell variety of sarcoma may
be permanently cured by complete removal. Round-cell
sarcoma returns ; often very promptly, sometimes not for
several years. The life of the patient may not be
materially prolonged by the removal of a round-cell
sarcoma ; but the course of the disease may often be ren-
dered less painful, and a respite secured, even though the
recurring growth may seem to progress more rapidly.
Tuberculosis of the choroid is rare. It causes
DISEASES OF THE CHOROID. 353
rounded yellowish spots, which grow rapidly without pig-
ment-changes, but rarely reach the size of the optic disk.
These require no treatment. Sometimes it forms a single
large mass resembling sarcoma, for which the eye should
be enucleated.
Carcinoma and adenoma occur, the former as a
rare tumor usually secondary to carcinoma of the breast.
ANOMALIES OF THE IRIS AND CHOROID.
Anomalies of the Iris. — The iris is never of uni-
form color throughout, nor are the markings precisely
alike in the two eyes. When the differences of color are
very striking the condition is termed heterochromia. The
small dark masses at the edges of the pupil, called ectro-
pion of the uvea have been already alluded to (see page
331).
The fibrovascular membrane which occupies the pupil
in early fetal life, is sometimes incompletely removed,
leaving one or more threads of opaque tissue which ex-
tend into or across the pupil, called persistent pupillary
membrane. Such threads are distinguished from posterior
synechias due to iritis by the fact that they are attached
not to the pupillary margin of the iris, but distinctly to
its anterior surface. If numerous, they may connect with
a mass lying in the pupil, and attached to the anterior
FIG. 112.— Persistent pupillary mem- FIG. 113. — Polycoria seen by oph-
brane, usually gray or the color of thalmoscopic illumination,
the iris.
surface of the lens. The more common appearance is
shown in Fig. 112.
Anomalies of the Pupil.— Displacement of the
pupil from its position near the center of the iris is called
corectopia. Multiple pupil is called polycona. Only
23
354 ANOMALIES OF THE PUPIL
one of such pupils is supplied with a distinct sphincter,
except in the case where the normal pupil is divided into
two by a persistent pupillary membrane. Sometimes the
pupil is extended in a certain direction, usually down-
ward, by a deficiency of the iris-substance. This is called
coloboma of the iris. The anomaly may amount to only
a slight notch in the margin of the iris, may extend partly
across the iris, or may include its whole width, the pupil
reaching behind the margin of the cornea. It may vary
in width and shape. A common form is shown in Fig.
FIG. 114.— Congenital coloboma of the iris, pupil extending downward, below
the lower margin of the cornea.
114, as seen by oblique illumination. It may accompany
coloboma of the lens as shown in Fig. 133, which re-
presents its appearance as seen with the ophthalmoscope.
Its form is more rounded than that of the coloboma
usually left by iridectomy (see Fig. 165). In rare cases
the pupil extends the whole width of the cornea, no iris
being visible. This is called aniridia or irideremia.
With the ophthalmoscope a dark line shows the margin
of the lens against the general red ground of the fundus-
reflex.
Coloboma of the choroid occurs in two forms. In
one the deficiency of the choroid, allowing the white sclera
to be seen through it, extends backward from the ciliary
region (usually from below) toward the optic disk, some-
times not extending to it, sometimes including it. This
form is frequently accompanied by coloboma of the iris
and lens. It is illustrated in Fig. 115. The other form
consists of a rounded, area, sometimes situated at the
macula, sometimes in other parts of the fundus. The
coloboma is often crossed by retinal vessels, sometimes
ANOMALIES OF THE CHOROID. 355
also by large choroidal vessels. Its margins always show
pigment-masses, and some pigmentation may be scattered
over its surface. It may be divided, as in Fig. 115, by a
FIG. 115.— Coloboma of the choroid of the left eye. Below the optic disk is
seen a small oval coloboma, and below it a larger one that stretches forward
probably to the ciliary body. Retinal vessels cross it, and a choroidal vessel
runs out into it.
narrow strip of normal or nearly normal fundus. It may
be of about the same level as the adjoining fundus, or
considerably depressed in portions or throughout. It is
distinguished from choroidal atrophy, albuminuric retin-
itis, and opaque nerve-fibres, chiefly by its regular rounded
form, and from the last two by the pigmentation of its
margin (compare Fig. 115, with Figs. 110, 117, and 125).
Albinism. — The absence of pigment from the uveal
tract accompanies the yellowish-white hair, eyebrows and
lashes, and the absence of pigment in the skin, that char-
acterize the albino. The iris usually appears a dull
leaden-blue or gray, the pupil may show a red reflex even
by ordinary illumination. With the ophthalmoscope the
356 ALBINISM.
pink fundus-reflex may be obtained through the iris.
The whole fundus appears yellowish-white, with the optic
disk very pink by contrast. The choroidal and retinal
vessels are seen with equal distinctness, and apparently
intermingled. The condition is liable to be hereditary
or to affect brothers and sisters. It is in most cases
attended with very marked errors of refraction, especially
high astigmatism and hyperopia. The eyes are habit-
ually partly closed, to lessen the amount of light entering
them, and to diminish the effects of imperfect focussing.
Such eyes require the careful correction of refractive
errors, and guarding from sudden changes of illumina-
tion.
Minor Anomalies of Pigmentation. — The choroid
presents all grades of pigmentation, from complete absence
in the albino, to me dark saturation which gives the negro
fundus a dark brown, rather than red appearance. Oc-
casionally isolated black or brown points or patches of
pigment are seen as congenital anomalies, often but a
single one, sometimes several scattered through the
fundus. Sometimes one or more large irregular patches
of the sort, resembling the common representations of
sun-spots, may be found in the macula. Such anomalous
pigment-deposits are distinguished from those of atrophy
by the absence of thinning or other defect of the choroid.
They cause no impairment of vision.
DISEASES OF THE RETINA. 357
CHAPTER XII.
DISEASES OF THE RETINA.
General Considerations. — The retina is an off-shoot
of the central nervous system. This, and the physical
conditions under which it is placed, influence the char-
acter of its diseases and give them especial interest.
Disturbances of its function are capable of minute local-
ization and exact study, and the greater part of the retina
is absolutely open to inspection, under magnification most
useful for the connection of symptoms with pathologic
alterations. These facts give its diseases immense impor-
tance in the study of general pathology. For the gain-
ing of definite conceptions of pathologic processes, ophthal-
moscopy offers advantages in many ways superior to those
afforded by the microscope or the post-mortem room.
The neurons of the retina, like those of the brain, have
their function disturbed or depressed below the level of
consciousness by pressure. Yet they are capable of re-
gaining function, if the pressure be not too severe or
prolonged. Their function is similarly depressed by
impaired circulation ; and if the impairment continue
long enough, degenerative organic changes follow. The
retinal neurons are also sensitive to toxic influences
exhibiting varying degrees of susceptibility, and illus-
trating most minutely and significantly the essential
phenomena of poisoning.
It should be borne in mind that the optic nerve is but
a commissure connecting the retina with various other
parts of the central nervous system. The diseases classed
as belonging to the optic nerve, and the amblyopias, are
largely retinal diseases ; so that this and the succeeding
chapter must be considered together.
Symptoms of Retinal Disease. — The diagnosis of
diseases of the retina rests upon studies of functional
impairment by tests of vision, visual field, and color vis-
ion ; and the use of the ophthalmoscope. Most of them
are named as forms of retinitis, but some so named might
more properly be spoken of as degenerations.
358 SYMPTOMS OF RETINAL DISEASE.
Impairment of Vision. — Retinal disease, not manifest
in any other way, will cause impairment of vision. There
may be abnormal after-images, or deficient power of re-
covery from the changes produced by exposure to light,
which may lead to impairment of vision in strong light,
day-blindness; or its undue impairment in diminished
light, night-blindness. The latter is apt to occur endemi-
cally when nutrition is impaired, especially by lack of food,
or confinement. The retina, otherwise normal, may so
suffer from prolonged exposure to excessive light as to have
its sensitiveness greatly impaired, even for comparatively
strong illumination, snow-blindness. This occurs from
exposure in high mountains and in polar regions. It is
distinct from retinitis due to excessive light (see page 371).
Hyperesthesi^ of the retina shows itself by discom-
fort in the presence of strong light, and attempts to avoid
it ; but without the tendency to close the lids, and press
upon them, which is shown in the photophobia of con-
junctivitis or keratitis.
Metamorphopsia, due to displacement of the percipient
elements of the retina by exudation, is usually noticed
when retinitis involves the region of the macula. Fine
parallel lines, when their images fall on the affected area,
appear crowded together from separation of the retinal
elements, or spread apart by crowding together of these
elements ; or a straight line appears to have an angle at
the point looked at ; or one portion of the line appears
displaced as regards the other portion. These appear-
ances are most noticeable when the line is turned in some
special direction.
Hyperemia of the retina is recognized chiefly in the
enlargement of the larger retinal vessels. These vary
markedly in caliber in normal eyes, so that only extreme
departures from the usual standard can be classified as
abnormal, unless the eye in question has been recently
examined ophthalmoscopically. Tortuosity of the ves-
sels is a more definite evidence of increase in their full-
ness ; but even very marked tortuosity may occur as a
congenital anomaly in perfectly healthy eyes, and may be
DISEASES OF THE RETINA. 359
limited to a single retinal vessel (see also page 92). Undue
redness of the optic disk is apt to occur with retinal hy-
pereraia.
Anemia of the retina of a moderate degree is even
harder to recognize with certainty than is hyperemia. It
is shown by narrowing of the vessels, and straightening
of their course. Acute anemia of the retina with ex-
treme contraction of the retinal arteries, the veins being
broad and dark with pallor of the optic disk, and sud-
den blindness is called ischemia of the retina. It occurs
after excessive hemorrhage, as metrorrhagia, and in acute
disease, as erysipelas, and cholera. In quinin-blindness
both arteries and veins are contracted. Both hyper-
emia and anemia of the retina are frequently judged
present or absent merely by the hyperemia or anemia of
the optic disk ; but it must be remembered that the cir-
culation of the optic disk is even more intimately con-
nected with the circulation of the choroid than with that
of the retina.
Alterations of the Vessels. — General anemia shows
itself in the retina by quite other signs than those of
retinal anemia. The retinal veins become broad and pale
with a wide light streak. Changes in the blood, as in
diabetes, may alter the color of the retinal vessels so that it
becomes difficult to distinguish arteries from veins or
either from the general color of the fund us. Patches of
fatty degeneration causing a glistening white appearance
may be found in the walls of the vessels, particularly in
connection with albuminuric retinitis. The affected por-
tion of the vessel appears as a white band, and beyond it
the vessel may assume the normal appearance, or whole
vessels may be thus altered to white streaks. This ap-
pearance is quite different from that of the faint gray
lines seen on either side of the vessel where it crosses
another vessel or other dark background upon the optic
disk ; and which may also be seen to extend beyond the
disk, in eyes that have been the seat of retinal inflamma-
tion, or in vascular disease.
Irregularities of caliber are noticed in the retinal vessels,
360 ALTERATIONS OF THE VESSELS.
imassociated with marked retinal disease, or great disturb-
ances of the general circulation. They may also be seen
after neuroretinitis and as an early symptom of renal vas-
cular disease, or of grave disturbances of the cerebral cir-
culation or of cerebral hemorrhage. Pulsation of the ves-
sels is elsewhere discussed. (See page 86 and Chapter XV.)
Retinal hemorrhage appears as one or more dark red
spots, which slowly disappear with the decoloration of the
clot, and may be succeeded by white spots of fatty de-
generation. Hemorrhage is most frequently situated in
the nerve-fibre layer, where the effused blood pushes its
way between the bundles of nerve-fibres; giving the
patch a striated appearance, especially noticed at the
margins, in the directions the nerve-fibres run. Hemor-
rhages of this shape and appearance are called flame-
shaped. They are illustrated in Plate I, 2, and Figs. 116
and 117. Hemorrhage into the deeper layers of the retina
does not present this appearance, but has a rounded* edge
in all directions, and the retinal vessels may sometimes
be seen to cross in front of it, although almost invisible
against such a background.
A large patch of hemorrhage hiding the retinal vessels,
and having a rounded outline, especially liable to Cover
the macula, and often slowly shifting position from day
to day under the influence of gravity, is called a subhya-
laid hemorrhage because it is located not in the retina but
on its surface. Such a hemorrhage may undergo complete
absorption, with full restoration of acuteness of vision.
This rarely or never happens when the hemorrhage occurs
in the retina.
Retinal Opacity from Exudate. — The transparency
of the retina is markedly impaired by the presence of
exudate, even by simple edema. If the swelling be great,
the normal red of the fundus may be entirely replaced in
the affected area by a gray or bluish color, closely resem-
bling the appearance of detached retina. Above and
below the optic disk Avhere the nerve-fibre layer is thick-
est, the distribution of the exudate between the nerve-
fibre bundles gives the retina a striated appearance, some-
DISEASES OF THE RETINA. 361
what like that of partial opaque nerve-fibers. In other
parts of the retina the areas of swelling and opacity have
rounded outlines, which may be quite distinct, or the
patch may shade imperceptibly into normal fundus. The
appearances produced by retinal exudates are most pro-
nounced in those regions where the retina is thickest,
about the optic disk and macula, and are scarcely dis-
cernible at the anterior peripheral parts of the retina.
The haze of retinal swelling usually covers and conceals
portions of the retinal vessels ; but where the vessel lies
entirely upon the surface of the retina the gray back-
ground of the swollen retina causes it by contrast to stand
out with unusual distinctness. This is illustrated in Fig.
116.
Fatty degeneration may take place in the connective-
tissue elements of the retina, or in exudates into the retina,
and especially the remains of hemorrhages. It causes
spots that may have a dirty yellow or reddish hue, but
which in most typical cases are pure glistening white.
These may be arranged in characteristic figures, as in
albuminuric retinitis and in circinate retinitis.
Pigment-changes. — The layer of hexagonal pigment-
cells lying next to the layer of the rods and cones belongs,
embryologically, to the retina. It is properly called the
retinal pigment-layer. Loss of its pigment renders visible
the vessels and intravascular spaces of the choroid ; and
is usually associated with choroidal disease, as in myopia.
(See Fig. 63.) This pigment is always scanty at the
periphery of the retina, and often becomes absorbed as a
senile change. In certain diseases pigment is deposited
in the more superficial layers of the retina and especially
along the vessels, covering portions of them as with a
blanket, and to that extent concealing the vessels. (See
Fig. 118.) These pigment-deposits are associated with
chronic disease, or may mark the site of former hemor-
rhages.
Atrophy of the retina occurs as a sequel to diseases
of the retina or optic nerve, or both ; especially from
embolism or thrombosis of the central vessels of the
362 ATROPHY OF THE RETINA.
retina, or atrophy of the optic nerve. It is indicated by
great diminution in the size of the retinal vessels, and
sometimes by absence of the retinal pigment.
RETIN1TIS.
Simple retinitis (edema of the retina, serous retin-
itis) is characterized by more or less opacity of the retina,
which may be limited to a few small spots, or may involve
a large part of the retina in the region of the posterior
pole. It may affect one or both eyes. The vessels are
usually somewhat broad and tortuous, some of their curves
being veiled by the hazy retina. Vision is impaired over
the portion of the field corresponding to the aifected
retina.
Etiology and Diagnosis. — This disease may be caused
by eye-strain, or by unrecognized constitutional conditions.
Other forms of retinitis often begin by simulating this
one, and only acquire their special characters later. The
diagnosis is made by excluding the causes of the special
forms of retinitis. But it is sometimes difficult to dis-
tinguish the haziness due to retinal swelling, from that
due to vitreous opacity, or the blurring caused by astig-
matism (see page 176) ; and marked edema may be mis-
taken for detachment of the retina.
Treatment. — Simple retinitis requires rest of the eyes
in a moderate and constant light ; often with correction
of errors of refraction, sometimes with the continued use
of a mydriatic. A mild purgative may be given, and fol-
lowed by the use of iodids in small doses. The general
health should be attended to. Under such treatment
recovery is usually complete, if the case be truly one of
simple retinitis. A few cases with dense masses of
exudate may have corresponding permanent scotomas.
Purulent Retinitis (Metastatic or Embolic Retinitis).
— Clinically this disease cannot be distinguished from
purulent choroiditis (see page 341), except that it more fre-
quently runs the chronic course that results in pseudo-
glioma. It is distinguished by the microscope after the
DISEASES OF THE RETINA.
363
eye has been enucleated. It is caused by wounds, par-
ticularly by foreign bodies penetrating the cornea and
lodging in the vitreous, without injury to the choroid ;
and by metastasis in the course of puerperal fever, py-
emia, etc.
Sometimes, in connection with septic disease, small
white spots and hemorrhages appear scattered in the
retina, without other inflammatory symptoms, or much
impairment of vision. This condition is called septic
retinitis.
I/eukemic Retinitis or Neuroretinitis. — Profound
leukemia, and pernicious anemia, are apt to be attended
by a form of retinitis in which there is great and general
r
FIG. 116.— Leukemic retinitis of left eye. The optic disk is entirely hidden
by swelling, and ill-defined light patches of exudate hide parts of the retinal
vessels. The macula is slightly affected. Several "flame-shaped" hemor-
rhages are shown by darker patches.
swelling and opacity of the retina, often extending upon
the optic disk. There is enlargement of the retinal
veins, sometimes enormous, and, in the later stages,
364 LEUKEMIC RETINITIS.
numerous flame-shaped hemorrhages. The appearances
are represented in Fig. 116. If the case be sufficiently
chronic some of the patches of more dense exudate may
show evidence of fatty degeneration. The general color
of the fundus is light and often strikingly yellow ; and the
vessels are broad and pale, with visible sheaths. Both
eyes are affected, although often to different degrees.
Etiology and Diagnosis. — The essential cause is the
leukemia, or pernicious anemia ; and its recognition with
that of the retinal changes, establishes the diagnosis.
Much the same retinal changes have been seen in cases
of profound anemia from other causes, and in connection
with hemophilia. Malarial disease of the retina may
present much the same appearances.
Treatment and Prognosis. — The treatment is that of
simple retinitis, with the treatment of the leukemia.
The retinal lesions commonly appear late, and do not
often improve much, continuing to grow worse until the
fatal termination of the general disease. Usually they
do not cause blindness. Improvement in the general
condition may lead to great improvement in the retinal
swelling, with improved vision.
Hemorrhagic Retinitis (Apoplexy of the Retina).—
Sometimes with a history of rather rapid impairment of
vision, usually in one eye or to a greater extent in one
eye than the other, a patient presents numerous flame-
shaped hemorrhages scattered throughout the fundus,
with some swelling and opacity of the retina. One eye
may remain unaffected, but usually both become involved,
although sometimes not the second until months or years
after the first. If the case be watched, fresh hemorrhages
are detected from time to time ; and Avhite or yellowish
spots, or areas of pigment disturbance, follow7. The
optic disk may be red and swollen. The retinal veins
are dilated, but the arteries may be rather small.
Etiology and Diagnosis. — The disease is most fre-
quently seen in elderly persons, although some retinitis
may accompany recurring hemorrhages in young men.
In all cases it is probable that the vessels of the retina
DISEASES OF THE RETINA. 365
are diseased ; and the extra-ocular vessels, too, are gener-
ally abnormal. In some of the cases there is a thrombo-
sis of the central vein of the retina. But in general the
causes are not clear. The recognition of such a condition
as Bright's disease would of itself remove the case into
another class. Some hemorrhage is likely to occur in
most forms of retinitis.
Treatment and Prognosis. — Rest of the eyes, pro-
tection from strong light by dark glasses, and the local
abstraction of blood from the temple, are recommended.
Subconjunctival bloodletting has been tried by Cross.
The avoidance of excitement and the correction of any
abnormality in the circulatory or digestive systems, are
of equal importance. But in spite of treatment, hemor-
rhages recur, and sight is permanently damaged, even in
young patients. In the larger number of elderly patients
the eye is rendered practically blind. There is consider-
able danger of a subsequent rise of tension, causing a par-
ticularly intractable form of glaucoma ; and the probability
of death within a few months or years, especially from
cerebral hemorrhage, is relatively great.
Albuminuric Retinitis (Renal-vascular Retinitis,
Retinitis of Bright's Disease). — This disease is chiefly
encountered among elderly people, who come seeking
relief for impaired vision. The onset of the symptom is
often sudden, corresponding with the occurrence of hemor-
rhage or swelling in the region of the macula. The
ophthalmoscope shows spots or patches of hemorrhage or
fatty degeneration scattered throughout the retina ; or
grouped in certain portions, especially about the macula.
The retinal vessels are irregular in caliber, especially the
veins, parts of which may be dilated and tortuous. Some-
times the retina over an extensive area about the optic disk
and macula is greatly swollen, and of a dirty reddish or
yellowish color, or even glistening white. Usually the
optic disk is reddened and its margin obscured by swell-
ing.
Examination shows diminished elimination of urine,
and the presence in it of albumin and casts, although
366
ALBUMfNUR-IC RETINITIS.
albumin may at times be absent, and the casts not numer-
ous. Close questioning will generally reveal some chronic
impairment of health, especially nausea and headache ;
and almost invariably the arteries throughout the body
show undue rigidity, and the pulse is tense though often
small.
Etiology and Diagnosis. — In addition to the causes
of simple inflammation of the retina this form of retinitis
FIG. 117.— Albuminuric neuroretinitis of left eye. The disk is hidden by a
moderate vascular swelling. The macula shows the stellate grouping of white
dots and streaks, and above and below are indefinite patches of retinal exu-
date. A branch of the superior temporal artery directly above the disk has
turned white, and there are numerous flame-shaped hemorrhages. The reti-
nal veins are irregularly dilated.
clearly depends on the general degenerative changes of
grave renal-vascular disease. It may occur in acute
Bright's disease, after scarlatina, in lead poisoning, or
with the albuminuria of pregnancy. But the largest
number of cases occur in chronic interstitial nephritis, at
a time when increased arterial tension can no longer keep
up the normal excretion by the kidneys, when the ves-
DISEASES OF THE RETIXA. 367
sels have already undergone serious degenerative changes,
and the evidences of grave disease are beginning to
appear elsewhere. In the presence of these general dis-
turbances any evidence of retinitis, or even the mere
presence of isolated hemorrhages may class the case as
one of albuminuric retinitis.
The ophthalmoscopic appearances are, however, so typi-
cal that an almost certain diagnosis may be based on these
alone. They are illustrated in Plate I, 2, and in Fig. 117.
Fatty degeneration causes dots and larger areas of snowy
whiteness. In typical cases these are arranged in lines
radiating from the center of the macula, sometimes in all
directions, sometimes only in a limited sector of the region.
In other parts of the fundus the dots are scattered irregu-
larly, and are commonly less numerous. Usually a few
small scattered hemorrhages are found, although they may
be absent at a single examination. Sometimes the hem-
orrhages are large and very numerous.
The appearances in the macula are sometimes imitated
in optic neuritis from brain disease. But in those cases
there is always great swelling of the disk. Albuminuric
retinitis may also be attended with neuritis. But it
may present the macular changes without material changes
in the optic disk ; and when the disk is much affected
the retinal lesions are generally more extensive than are
found in connection with neuritis from other causes.
Alterations in caliber are most pronounced in certain
vessels, while others appear almost or quite normal.
Albuminuric retinitis, although not an early symptom
of renal-vascular disease, may be the first that reveals the
nature of the case. In all cases presenting suspicious
changes in the retina the condition of the kidneys, heart,
and general circulation, should be carefully studied.
Treatment. — As in other forms of retinitis the eye
should have rest. Reading must be suspended or greatly
limited. Errors of refraction or failure of accommoda-
tion should be carefully met by proper lenses, to be worn
whenever the eyes are used. Beyond this the treatment
is that of the general condition ; regulated diet, woolen
368 ALBUMINURIC RETINITIS.
clothing, removal to a dry mild climate, and careful
avoidance of worry, or mental strain. Internally strych-
nin in moderate doses is sometimes markedly beneficial.
Preparations of iron are valuable in many cases, but may
do serious harm in those showing a strong tendency to
develop fresh hemorrhages.
Prognosis. — Occurring immediately after scarlatina,
with acute Bright's disease, during pregnancy, or with
lead poisoning, albuminurjc retinitis may end in recovery,
often, however, not complete. Where it occurs with
chronic renal- vascular disease, if the eyes have been much
strained as by hard use, /insufficient help from glasses,
etc., complete rest of them may be followed by marked
improvement of vision. But in most cases, if the eyes
are used, repeated attacks of swelling and hemorrhage
occur, leaving vision more and more impaired. There is
a tendency sometimes to go on to atrophy of the retina
and the optic nerve ; but most patients retain quite useful
vision until death. As a sign of the general disease and
the approaching fatal termination of the case, albuminuric
retinitis is of great significance. (See Chapter XX.)
Gouty retinitis occurs in elderly persons subject to
other manifestations of gout. It causes progressive im-
pairment of vision, affects both eyes, is marked by yel-
lowish-white patches of exudation in the region of the
macula and disk, hemorrhages which occur chiefly in the
earlier stages, thickening and opacity of parts of the
walls of the vessels, marked narrowing of parts of the
arteries, and dilatation of parts of the retinal veins. The
vessels throughout the body give evidence of marked
sclerosis. The urine is of rather high specific gravity.
It contains a large amount of uric acid, rarely albumin,
and no casts. The treatment is that of the gouty diathesis
with rest for the eyes, and avoidance of excitement.
Blindness does not usually occur, but there is little or no
recovery of sight once lost ; and a large proportion of the
patients die of cerebral hemorrhage.
Diabetic retinitis occurs in the course of saccha-
rine diabetes. It is characterized by the appearance in
DISEASES OF THE RETINA. 369
the retina of small ivory-white dots ; most numerous
about the macula and toward the disk, but not arranged
in any stellate or regular figure. In a few cases large
white plaques have been seen, toward the periphery of the
fundus. The optic nerve is not affected. Rarely spots
of pigmentation are scattered through the fundus.
Minute points, or larger spots of hemorrhage are usually
seen ; and sometimes typical hemorrhagic retinitis is
encountered in diabetes. The treatment is that of diabetes ;
and the chance of improvement depends on the chance of
improving the patient's general condition.
Syphilitic retinitis and chorioretinitis occur as
secondary lesions ; sometimes rather early, but usually one
year or more after infection. They may run their course
without perceptible involvement of the choroid ; but in
the larger number of cases there are distinct spots of
choroidal infiltration, and later permanent atrophic and
pigment-changes. Not rarely the lesions of the posterior
portions of the eye accompany iritis. There is always
some opacity of the posterior part of the vitreous, dust-
like in character, gradually increasing and gradually pass-
ing away. (See Chapter XIV.) In the choroidal cases the
fundus is decidedly speckled. Retinal opacity is most
marked in a zone around the optic disk, or may be local-
ized especially in the macula. The optic disk is red,
hazy, and sometimes quite obscured, ultimately it may
present a yellowish-white appearance of partial atrophy.
The vessels are usually but little altered, but may be
narrowed in the later stages. Retinal hemorrhage is rare.
In a few cases, however, numerous hemorrhages of rather
large size are distributed throughout the fundus. Some-
times the inflammation is localized at the macula, and
shows an especial tendency to relapse.
Central acuteness of vision is lowered in all cases, and
scotomas of various forms are apt to occur. There is
night-blindness, excessive impairment of sight when the
illumination is slightly diminished ; and a persistent daz-
zling or shimmering of light that is very annoying.
Metamorphopsia occurs and is likely to be permanent.
24
370 SYPHILITIC RET1NITIS.
Diagnosis. — The dust-like opacity of the posterior
vitreous, the spots of gray or white, but not brilliant white
opacity of the retina, the speckled choroid, the red hazy
disk, the slight changes in the vessels, and the chronic
course of the disease constitute a characteristic picture.
The nature of the retinitis will be confirmed by a history
of syphilis or of other characteristic syphilitic lesions, and
the absence of other common causes of retinitis. But this
form of retinitis is one of the most characteristic single
lesions of syphilis, and, without other evidence of its
nature, should be regarded as syphilitic.
Treatment and Prognosis. — Retinitis of this character
should be met by the prompt, effective, and prolonged
administration of mercury. Inunctions should be given
at first. Subsequently, some other mode of administration
may be resorted to, but as much should be given as
possible without producing constitutional effects. The
eyes should be kept at rest, during the acute stage a
mydriatic may be used, and they should be protected
from excessive light or sudden changes of illumination.
At a late stage potassium iodid may prove useful. Under
treatment vision generally improves and the disease is
permanently checked ; but vision is very rarely restored
to normal, and in most cases permanent retinal lesions
are revealed with the ophthalmoscope.
Punctate retinitis (retinitis punctata albescens) is
characterized by a great number of white or yellowish-
white points scattered throughout the fundus, without
pigment-changes. Vision is usually somewhat impaired.
It is not progressive, and in most recorded cases has
probably existed some time before it was discovered.
Striate retinitis is characterized by light yellowish
or gray lines or streaks just back of the retinal vessels,
some straight as though drawn upon, others curved or
with branching ends. The streaks have not the direction
of the vessels or of other known structures. The disease
appears in early life. The streaks may mark a previous
detachment of the retina. Vision in the affected eye is
generally greatly impaired, but not entirely lost.
DISEASES OF THE RETINA. 371
Proliferating Retinitis. — Attacks of retinitis at-
tended with extensive hemorrhages sometimes result in
the formation of dense bluish-white or gray masses of
connective tissue, which extend from the retina into the
vitreous, hiding "completely certain parts of the fund us.
To this condition, which is seen more often as a sequel
than as an active pathological process, the above name is
applied.
Circinate retinitis is characterized by brilliant white
spots arranged in the form of a wreath near the macula
or disk. They lie behind the retinal vessels, may remain
unchanged for years; and are often accompanied, and
perhaps always preceded, by retinal hemorrhages. The
condition occurs mostly after middle life, and may affect
one or both eyes. Vision is always impaired, usually
growing worse gradually.
Retinitis from excessive light occurs from keep-
ing the gaze fixed on the sun without sufficient protection,
usually while watching an eclipse or looking for sun spots.
The ophthalmoscope shows little or no alteration of the
affected part of the retina, which may not be larger than
the fovea. There is a small central scotoma, persistent,
annoy ing, dazzling, and sometimes metamorphopsia. The
injury may be prevented by use of smoked glass so dark
that objects cannot be seen through it by ordinary illu-
mination, and through which the sun causes no persistent,
annoying after-image. When the injury has occurred,
rest for the eyes and avoidance of sudden changes of illu-
mination will be beneficial. If vision is not reduced
below one-third, recovery of normal vision may be ex-
pected in from one to six months, although careful test-
ing may still show the presence of a minute relative or
absolute scotoma.
Exposure to excessive light may be an exciting cause
of chorioretinitis, with ophthalmoscopic changes and
scotoma. Such a condition has followed exposure to a
stroke of lightning. Exposure without proper protection
to a powerful electric arc light, causes, besides the effects
of excessive light on the retina, violent smarting pain in
372
RETINITIS FROM EXCESSIVE LIGHT.
the conjunctiva, with swelling and inflammation, probably
due to something beside the light. The conjunctiva!
symptoms subside in a few days. The repair of the
retinal tissue sometimes requires much longer, and may
not be complete.
Pigmentary Degeneration (Retinitis Pigmentosa).—
This is usually congenital. From early childhood night-
blindness is noticed, the patient being practically blind in
a feeble light, although no defect may be noticed in good
daylight. The field of vision is restricted, usually con-
FIG. 118.— Pigmentary degeneration of the retina. The disk is white, the
retinal vessels are narrowed. The retinal pigment is atrophied, revealing
the choroidal vessels. The characteristic pigment-patches are seen in the
periphery.
centrical ly, at first only when in a feeble light. These
symptoms are slowly progressive, the patient becoming
helpless after sunset ; and the field of vision greatly nar-
rowed, although full acuteness of central vision may be
possessed in a good light.
The characteristic ophthalmoscope changes include
loss of the normal pigment from the retinal pigment-
DISEASES OF THE RETINA. 373
layer, and accumulations of pigment forming dark -brown
or black masses of a stellate or branching shape, compared
to that of bone-corpuscles. These masses often lie along
blood-vessels, around which they seem wrapped like a
blanket. They are first seen, and most numerous, in the
extreme periphery of the fundus, and gradually invade
the posterior or central portion, but rarely extend to the
immediate neighborhood of the macula and optic disk.
They are shown in Fig. 118. As the case progresses the
retinal vessels become greatly narrowed, and the optic
nerve atrophic. Both eyes are affected. Eyes presenting
this form of retinal degeneration are often highly ame-
tropic.
Etiology, Varieties, and Diagnosis. — Congenital cases
can often be traced to consanguinity of parents, heredity,
or inherited syphilis. Five to ten per cent, of congenital
deaf-mutes suffer from this disease. A form of the dis-
ease is seen as a tertiary manifestation of acquired
syphilis. It appears much later, often not until middle
age ; and is attended by choroidal atrophies and pigment-
accumulations. Cases may be found presenting ophthal-
moscopic appearances grading from those of typical
chorioretinitis to those of typical pigmentary degenera-
tion. In a few cases, the symptoms of which otherwise
are those of this disease, the pigment-accumulations in
the retina are entirely lacking. In typical cases the nar-
rowed field, night-blindness, slow progress, and ophthal-
moscopic symptoms are characteristic. In the atypical
cases careful consideration of all symptoms must deter-
mine where the case belongs.
Treatment and Prognosis. — The treatment consists
of careful and very moderate use of the eyes under the
best conditions, including the constant wearing of correct-
ing glasses, and protection from excessive light and sudden
variations of illumination. The internal use of strychnin
in moderate doses, the instillation of a weak solution of
eserin, and the applying of the galvanic current to the
eyeball have been recommended as beneficial. But no
treatment cures the disease, and it is doubtful if anything
more than general hygienic measures delays its somewhat
374 PIGMENTARY DEGENERATION.
irregular progress. The majority of patients become
hopelessly blind by the age of sixty years. The form
due to acquired syphilis is more amenable to treatment ;
and, while running a comparatively rapid course, is not
so sure to go on to complete blindness.
Amaurotic Family Idiocy (Infantile Cerebral De-
generation, Symmetrical Changes at the Macula, Tay's
Choroiditis). — This disease attracts attention during in-
fancy or early childhood, by inability to see, or general
progressive muscular weakness, without evidence of
localized lesions of the nervous system. Ophthalmoscopic
examination shows a rounded gray or white area occupy-
ing the center of each retina, with usually a dark-red or
brownish-red spot, corresponding to the center of the
macula, somewh§ t like the appearance in embolism of the
central artery of the retina. In a few months the optic
nerve atrophies, the patient becomes entirely blind, and
the muscular weakness increases, until the disease ter-
minates in death. Autopsies show degeneration of the
large nerve-cells of the retina and the pyramidal cells of
of the cerebral cortex. Several children of the same
parents may be affected ; and the reported cases have
been of Jewish parentage.
Angioid streaks in the retina are brown streaks
of pigment, often with lighter borders, forming an irregu-
lar network like a system of anastomosing vessels, but
not related to either retinal or choroidal vessels. They
may follow retinal hemorrhage or detachment.
Retinal Macular Atrophy (Hole in the Macula). —
This may result from injury to the eye, from senile change,
or other serious disturbance of nutrition. A dark oval
spot, half the size of the optic disk, seen at the macula,
seems depressed below the general surface of the retina.
Spasm of the retinal arteries sometimes occurs,
causing temporary blindness. Usually it lasts but a few
seconds, but it may recur. If more permanent, it leads to
thrombosis, and permanent vascular obstruction.
Obstruction of the retinal vessels causes blind-
ness, usually sudden. It may be due to endarteritis,
thrombosis, embolism, or combinations of these condi-
DISEASES OF THE RETINA. 375
tions. Thrombosis usually occurs, whatever the primary
cause of obstruction. It is often impossible to determine
the primary condition ; although primary venous throm-
bosis is credited with causing more extensive retinal hem-
orrhage. When the circulation of the whole retina is
obstructed, blindness is complete and usually permanent.
When a limited part of the retina is involved, a corre-
sponding part of the visual field is lost. If the macula
be supplied by vessels that escape entirely, as cilio-retinal
vessels, central vision may remain unimpared, while the
field is greatly narrowed. After permanent obstruction
the retina degenerates and atrophies.
Diagnosis. — Retinal obstruction is recognized with the
ophthalmoscope. The branches of the artery do not at
first seem much altered in appearance, except as they are
concealed by retinal opacity. The veins are in some
portions greatly narrowed, and at other points of full
width or broadened by flattening. Sometimes the slow
return of blood in bead-like or longer masses, may be
seen in one or more branches of the retinal veins.
The central portion of the retina becomes quite hazy
within a few hours after the accident, giving that part of
the fundus a bluish-gray or white hue, except just at the
fovea where is seen in almost all cases a dark red spot.
The exudation and opacity may be more dense along the
vessels. Where the vessels dip into it they are partially
or wholly lost to view, and on this account may seem to
be narrowed or interrupted. Toward the periphery of the
fundus the gray opacity thins out until the color of the
fundus appears quite normal. Retinal hemorrhages may
occur, especially in the region of the macula.
The usual appearance of the fundus is shown in Fig.
119. After a few days the retinal haze begins to dis-
appear, but retinal degeneration keeps the central part of
the furtdus white, with its distinct central red spot, some-
times for several weeks. At a later stage there remains
only a complete atrophy of the optic nerve, with extreme
narrowing or obliteration of retinal vessels.
Treatment and Prognosis. — In a few cases the em-
bolus has, spontaneously, become broken up or displaced,
376 EMBOLISM OF RETINAL ARTERY.
and the retinal circulation partly or wholly restored. In
a few cases the same result may be brought about by
active massage of the eyeball, or by temporary dilatation
of the artery by inhalations of nitrite of amyl. Both of
these measures should be tried, and repeated two or three
times a day during the first ten days or two weeks after
the occurrence of embolism. If they fail to influence the
FIG. 119.— Embolism of the central artery of the retina on the third day. The
arteries are little altered in appearance; the veins are irregular from partial
collapse. The superior temporal vein shows the bead-like appearance. The
center of the fundus is gray with edema, except the center of the macula,
which appears as a dark round spot.
obstruction, there is sometimes a partial re-establishment
of the circulation through shrinking of the embolus or
relaxation of the arterial walls, with return of vision in
some part of the field. But generally the blindness is
permanent. With complete blindness, after the first two
or three weeks the case must be regarded as hopeless.
Thrombosis of the retinal artery probably arises
in connection with degenerative changes in the arterial
DISEASES OF THE RETINA. 377
walls, or spasm of the muscular coat. The symptoms
resemble those of embolism, except that the onset of
blindness may not be quite so sudden, or may be attended
with temporary blindness of the other eye, giddiness,
faintness, or other evidence of disturbance of cerebral cir-
culation. Attacks of temporary blindness through brief
arterial spasm may have preceded the thrombosis.
Thrombosis of the Retinal Veins. — The symp-
toms of this condition resemble somewhat those of em-
bolism of the retinal artery. The veins are enlarged and
tortuous, although the arteries may be narrowed. Hemor-
rhages are numerous, especially about the optic disk,
which may be extremely red. Loss of vision is less sud-
den than in embolism, and there is more likely to occur
a return of the circulation, at least in some of the vessels,
and a partial restoration of sight. The patient should be
kept quiet, and on a restricted diet, unless this is contra-
indicated by his general condition. Saline laxatives may
be given, or venesection resorted to.
Detachment of the Retina (Co-arctation of the
Retina, Amotio Retince}. — Separation of the retina from
the choroid by serous fluid had been before noticed by
oblique illumination, and in dissecting enucleated eyes.
But the use of the ophthalmoscope has shown it to be a
not rare condition.
Symptoms and Course. — The detached portion of the
retina becomes blind, although in rare cases it may re-
tain light-perception for some time. It may also suddenly
cut off vision, by falling in front of a part still normalr
Usually the patient complains of sudden impairment of
vision, which on investigation is found to affect only a
portion of the field. There may for a time be sufficient
power of vision retained in the detached retina to allow
a noticeable metamorphopsia, or to cause annoying vertigo
from displacement, and movement of the percipient ele-
ments. Any part, but more commonly the anterior por-
tion, may be the starting-point of detachment. But by
the gravitation of subretinal fluid the lower part of the
retina usually becomes affected. Ultimately the whole
378 DETACHMENT OF THE RETINA.
retina is drawn away from the choroid, retaining only its
attachments at the optic disk and its anterior margin,
having somewhat the shape of a straight trumpet with
the shrunken vitreous lying within it. Both eyes may be
affected, but in the majority of cases one escapes. After
the detachment has become complete, the lens often
becomes opaque, and other degenerative changes occur.
The tension of an eye with detached retina is likely to be
below normal.
With the ophthalmoscope the retina appears as a some-
what opaque, gray membrane, floating in rounded folds ;
upon which may be traced branches of the retinal vessels,
apparently very small because displaced forward so much
within the focus of the lens through which they are seen.
Where the retina is viewed obliquely its opacity is most
evident. Through parts that are nearly perpendicular to
the surgeon's line of sight the red reflex of the choroid
may be seen. Where the retina is but slightly and
recently separated from the choroid, no opacity may be
perceived ; and the detachment may be revealed only by
the displacement of the retinal vessels. Sometimes dis-
tinct tears are found in the retina, through which the
choroid may be seen. Portions of the retina which are
just becoming detached may exhibit a peculiar fine
mottled reflex, which may be compared to the reflexes
from " pebbled " leather. The more striking appearances
of detachment of the retina are shown in Fig. 120.
Causes. — Detachment of the retina occurs more fre-
quently in men than women, and the liability to it
increases with age. It may be caused by bruise or by
perforating wounds of the eyeball either at once, or sub-
sequently by cicatricial changes. Highly myopic eyes
are chiefly liable to it, and choroidal disease, hemorrhage,
or an intra-ocular growth may cause it. It may appear
after a special effort, as coughing, vomiting, or heavy
lifting.
Diagnosis. — Sudden impairment of vision in one eye
affecting chiefly or solely a portion of the visual field,
should always suggest this affection. With the ophthal-
DISEASES OF THE RETINA.
379
moscope its situation and extent can usually be studied.
If, on account of opacity in the cornea, lens, or vitreous,
this is not possible, careful mapping of the field of vision
must be relied on.
When detachment is recognized, it is necessary to
determine if the separation is caused by fluid (simple
detachment) or by a new growth, as sarcoma of the
choroid. This will be done by noting the presence of
large vessels or a distinct mass beneath the retina, the
FIG. 120. — Detachment of the retina, seen with a strong convex lens which
focusses for the detached portion below, and leaves the normal fiindus
above quite out of focus. Note the rounded folds which float on liquid, and
the very small retinal vessels upon them.
absence of any wavy motion of the retina, and the nor-
mal or increased tension of the globe in case of new
growth ; or the absence of any tumor visible through the
retina, the wavy movement and alteration in the form
of the folds caused in it by movements of the eye, and
the normal or diminished tension in the eyeball in simple
detachment. A new growth concealed beneath detached
retina which floats upon fluid surrounding the growth may
be revealed by strong illumination, as direct sunlight.
380 DETACHMENT OF THE RETINA.
It is sometimes difficult to distinguish between a small
detachment, and a limited swelling and opacity of the
retina in retinitis. Unless there be distinct folding or
floating of the affected area, it should usually be regarded
as swelling rather than detachment, even though the
pushing forward of the retina amounts to 4. or 5. D.
Treatment. — This should include rest in bed, with
absolute rest of the eyes, best under a pressure-bandage.
Pilocarpin sweats have sometimes proved of benefit ; as
have potassium iodid, or salycilic acid in moderate doses.
The injection of tincture of iodin or similar substances
into the eye is not to be recommended. In many cases
the withdrawal of the subretinal fluid by an incision in
the sclera, has produced great temporary improvement;
but generally ther» has been a subsequent return of the
detachment. Recently Stillson has reported more perma-
nent relief by making, by the galvanocautery, one or two
round holes in the sclera beneath the detachment.
Prognosis. — Spontaneous reattachment of the retina
occurs in rare cases. Treatment fails to cure in most
cases. The chance of recovery, or of the detachment
remaining partial, is better for traumatic than for spontan-
eous detachment. Most cases of detachment with high
myopia or choroiditis, become total.
Subretinal cysticercus is seen occasionally in Europe,
but no case is reported in America. One case of sub-
retinal echinococcus has also been recorded.
Glioma of the retina (or gliosarcoma) is a malig-
nant growth that occurs in early childhood. It may be
present at birth, or appear during infancy. It affects
one or both eyes, and tends to a fatal termination through
extension to the brain, or by exhaustion.
Symptoms and Course. — Attention is first attracted
by a shining yellowish-white reflex from back of the
pupil ; and the eye is found to be blind. Beer called it
" amaurotic cat's-eye." The tumor grows rapidly and may
fill the globe in a few months. As it grows, increase of
ocular tension occurs, and symptoms of inflammation
arise. The eye becomes red, painful, and tender. Usually
DISEASES OF THE RETINA. 381
it passes through the same stages as sarcoma of the
choroid (see page 350) ; but the first and second stages
do not usually last so long as the corresponding stages of
sarcoma. The method of extension is through the optic
nerve to the brain, and by metastasis to other organs. In
a few cases the inflammatory symptoms include a severe
iridocyclitis, which may end in diminished intra-ocular
tension and partial shrinking of the eyeball. This has
the effect of completely masking the original disease,
causing a variety called cryptoglioma.
Diagnosis. — Glioma is distinguished from pseudo-
glimna by growth of the tumor, by its rounded lobules,
by the presence of minute vessels upon it (although this
has been simulated by pseudo-glioma), by the absence of
any history, or cause of purulent choroiditis, or retinitis,
and by normal, and later increased tension, instead of the
lowered tension common in pseudo-glioma.
Treatment. — The affected eye should be removed at
the earliest possible moment, with as much of the optic
nerve as can be taken with it. If there is any probability
that the growth has already extended beyond the eyeball,
the orbital contents should also be removed ; and it may
be wise to remove and cauterize portions of the walls of
the orbit.
Prognosis.-— Removal while the growth fills but a
small part of the vitreous is likely to effect a permanent
cure. Removal while the growth is still confined within
the globe offers a fair chance, one in three, of cure.
Removal after the orbital tissues are involved is likely to
be followed by recurrence. Operation is useless when the
tumor has extended beyond the orbit ; and without
removal, early death is certain.
Anomalies of the Retina. — The most striking of
these, opaque or medullated nerve-fibers, has been suf-
ficiently described (page 91); the characteristic appearance
is shown in Fig. 121. Accumulations of pigment have
also been mentioned (page 99). The arrangement and
distribution of the retinal vessels varies greatly. Some
of the more common forms are shown in Plates I and II
382
ANOMALIES OF THE RETINA.
and Figs. 72, 84, 87, 90, and other illustrations of the
fund us.
FIG. 121.— Medullated or opaque nerve-fibers in the retina of the right eye.
Some parts of the retinal vessels are hidden. The striations take the normal
course of the nerve-fibers.
Anomalies of the macular region are especially
liable to mislead the ophthalmoscopist. The usual ap-
pearances have been described (page 88). Not rarely, one
encounters small white, or yellowish white dots which
may suggest albuminuric or diabetic retinitis ; or inflam-
mation of the center of the choroid. Yet on careful
investigation, absence of any impairment of function
proves that these appearances are anomalous, rather than
pathologic. Very extensive alterations in the retinal
pigment, areas of thinning, and black blotches, are usually
accompanied with some impairment of vision. Yet this
may be trifling, compared with what might be expected
from the ophthalmoscopic appearances discovered.
Anomalies of the retinal vessels are most com-
mon. Some of these are illustrated in the accompanying
DISEASES OF THE RETINA.
383
figures. (A) shows an unusual parallelism between arteries
and veins, with a large pigment deposit of the class that
seems to have no pathologic significance. (B) shows the
other eye of the same patient which exhibited neither of
J
C D
FIG. 121 a.— A, B, C, D.
these peculiarities, but the lower temporal vein is looped
around the artery. In (C) are shown two large cilio-
retinal vessels and an anastomotic branch connecting the
lower veins. In (D) the upper retina is supplied by a
very large cilio-retinal artery.
CHAPTER XIII.
DISEASES OF THE OPTIC NERVE, VISUAL TRACT
AND CENTERS. AMBLYOPIAS.
Hyperemia of the Optic Nerve-head (Hyperemia
oi" Congestion of the Papilla or Optic Disk). — This is
shown by general redness of the optic disk, and increase
384 HYPEREMIA OF THE OPTIC NERVE.
in the number of the smallest visible vessels (see page 93).
The redness may be so great that there remains no con-
trast between the disk and the surrounding fundus. If
there be a distinct physiological cup, the bottom of this is
usually not reddened, but appears by contrast unusual ly
white and noticeable. But the normal hue of the optic
disk varies greatly, so that unless one has the other eye
normal, or a previous observation to make comparison
with, it is only in marked cases that he can say positively
that the nerve-head is hyperemic. Hyperemia is caused
by strain of the eyes, whether from ametropia, prolonged
use, or unfavorable conditions of eye-work ; by exposure
to strong light or heat, by injury, or in inflammation of
the anterior segment of the eye (as a foreign body in the
cornea), or conjunctivitis, and by the causes of hyperemia
and inflammation of the retina, or choroid.
Anemia of the optic disk, or papilla, is as difficult to
estimate as hyperemia. It causes the disk to appear
pale, comparatively uniform in color and devoid of small
vessels. It is a most important symptom of optic atrophy,
and may be produced by general anemia or by local
obstruction to the blood-supply. The surgeon who sees
large numbers of hyperemic disks is liable to think the
normal disk anemic by contrast.
INFLAMMATIONS OF THE OPTIC NERVE.
Neuroretinitis (PapiUordinitis). — Inflammation of
the optic nerve always involves the adjoining retina.
The swelling extends beyond the borders of the nerve,
and if there is opacity it hides the margin of the choroidal
opening. Still, if this is all, the case is spoken of as one
of optic neuritis. Retinitis extending to the margin of the
disk veils and may quite hide the choroidal margin ; and
if not attended by any swelling of the disk, it is properly
called retinitis.
The optic nerve and the retina forming one continuous
structure, with the closest anatomic and physiologic
dependences and relations, morbid processes affecting the
DISEASES OF THE OPTIC NERVE. 385
one, frequently extend to the other, and often the two
are almost equally involved. Any such extension, beyond
the limits above indicated, constitutes the case one of
neuroretinitis. Neuroretinitis occurs in connection with
renal-vascular disease, leukemia, gout, syphilis, lead
poisoning, and sympathetic ophthalmitis ; and severe
neuritis arising in the course of brain disease very often
extends so largely to the retina, as to warrant including
it under this head.
Optic Neuritis (Intra-ocular Optic Neuritis; Papil-
litis, Choked Disk). — Optic neuritis is of great importance
on account of the -evidence it gives of extra-ocular disease,
and its liability to end in optic atrophy. It may cause
no symptoms apart from the appearances revealed by the
ophthalmoscope. Vision may be unaffected by even
violent neuritis, and impairment of vision, when present,
may generally be regarded as due to a supervening optic
atrophy, rather than to the neuritis.
Symptoms and Course. — The essential symptoms of
optic neuritis are increased vascularity, swelling and
opacity of the nerve-head extending beyond the margin
of the disk. With the swelling always occurs haziness
of the nerve-head, so that the margin of the choroidal
opening, and the deeper details of the nerve-head, such
as the lamina cribrosa, and the deeper parts of the vessels
are blurred or hidden.
Swelling of the nerve-head is illustrated in Fig. 30.
It pushes forward the vessels which lie upon the disk so
that their refraction as measured with the ophthalmoscope
becomes more hyperopic. The extent of the swelling is
estimated by comparing the refraction of the most hyper-
opic of the vessels, with the refraction of the nearest part
of the neighboring retina, that appears unaffected.
Usually this is done in diopters of refraction, as a
swelling of 7 D. The actual depth in millimetres of
such a swelling may be found from the table on page 134.
When the swelling is slight, the disk red, resembling
in color the general fundus, and the physiological cup
obliterated, there may be little beyond the convergence
25
386
SYMPTOMS OF OPTIC NEURITIS.
of the retinal vessels to indicate the position of the nerve-
entrance. As the swelling increases, however, it becomes
distinctly more gray, and lighter than the usual color of
the fundus, on account of the separation of the minute
vessels by exudate.
When the swelling is slight, the larger retinal vessels
may be little altered in appearance, or slightly and uni-
formly enlarged. As the swelling becomes greater its
pressure upon them causes obstruction of the blood-
columns, so that the retinal arteries are narrowed, while
the veins appear broad, dark, tortuous, and often irregular
in caliber. Something of this appearance is illustrated
FIG. 122.— Optic neuritis in a case of tubercular meningitis, right eye. Optic
disk hidden by gray striated swelling; retinal veins very large and tortuous.
in Fig. 122 and in Plate II, 8. These changes in the
vessels, with sharp limitation of the swelling to the im-
mediate vicinity of the nerve-entrance, have caused severe
optic neuritis to be called choked disk.
DISEASES OF THE OPTIC NERVE. 387
.In the' majority of cases of marked neuritis, retinal
hemorrhages occur. Most frequently they are on or near
the swollen nerve-head, but sometimes in other parts of
the fundus. About the papilla they are very notably
striated, by extension, between the bundles of nerve-
fibers. In this situation it is often not easy to distinguish
between a small hemorrhage and a dilated blood-vessel.
In severe neuritis there are often small isolated patches
of exudate in other parts of the retina, particularly in
the direction of the macula. Extensive lesions of the
kind would place the case in the category of neuro-
retiuitis.
Perfect vision may continue for weeks or months in
spite of typical optic neuritis, with great swelling. In
many cases the impairment of vision is so slight as to
escape the patient's notice. But when the secondary
atrophic changes begin, vision may be lost very rapidly.
The two eyes may present very similar ophthalmoscopic
appearances, and yet one be practically blind while the
other retains almost full vision ; and the difference be-
tween the two may be merely that in the first eye the
process is a few days further advanced than in the second.
Usually, however, central vision is somewhat affected.
The patient complains of a mist before the eyes, or of
persistent after-images, and color-perception may be im-
paired. Careful testing often shows an appreciable en-
largement of the physiological blind spot. The concentric
or irregular contraction of the field of vision for form
and color is that described under optic atrophy.
The course of optic neuritis may be acute or chronic.
When dependent upon acute brain disease, rheumatism,
or suppression of menstruation, it may reach its height in
a very few days. In slowly growing brain-tumor, the
swelling may gradually increase for many months or for
years. In either case it tends to pass over into a stage
of atrophy. Although in some of the acute cases normal
vision may be preserved, some atrophy of the choroidal
margin, with permanent opacity of the disk and in the
vessel-walls, almost always remains.
388 COURSE OF OPTIC NEURITIS.
Of the stage of subsidence, failure of vision may be the
first sign. Usually the swollen papilla becomes paler,
and the visible vessels fewer, although some may still
be noticeably dilated, and meshes of new-formed vessels,
like those seen after hemorrhage in the vitreous, may ap-
pear. Fresh hemorrhages cease to appear, the swelling
, FIG. 123. FIG. 124.
FIGS. 123, 124.— Optic neuritis from brain tumor, right eye. FIG. 123 shows an
early stage, the disk obscured by swelling. FIG. 124 shows the last stage pass-
ing into optic atrophy.
decreases, the hyperopia of the most prominent vessels
gradually diminishes. The vessels themselves, especially
the veins, get smaller, the swelling grows paler, the out-
lines of the optic disk begin to show through it, and the
case passes over into one of consecutive atrophy (see
Plate II, 9, and Fig. 124).
Diagnosis. — At the height of a severe case, optic
neuritis is unmistakable. In the earlier stages it must be
distinguished from normal prominence of the optic disk ;
and the slight cases due to eye-strain must be separated
from those due to more serious conditions. At one time
the normal optic nerve-head was supposed to usually pro-
ject into the eye, and hence it was called the optic papilla.
In some eyes this is actually 'the normal condition. In
many eyes the most prominent vessels are hyperopic 1 or
2 D. as they pass off the disk. Such prominence must
be considered normal, even though the disk be quite red,
if there be no opacity to veil the disk-margin.
In cases of eye-strain, however, it not rarely happens
that with this prominence and redness of the disk, there is
DISEASES OF THE OPTIC NERVE. 389
also some " filling in " of the physiological cup, and suffi-
cient opacity to obscure the disk-margin, especially above
and below. Such a case may be regarded as one of optic
neuritis. But if the eye- strain be present, it may be
ascribed to that cause, unless symptoms of organic dis-
ease likely to cause optic neuritis be also noticeable. In
the latter case the diagnosis can only be made by watch-
ing the eye for some days. If the swelling and opacity,
increase,. even though slowly, and the retinal veins be-
come decidedly dilated and tortuous, serious organic dis-
ease in the brain or elsewhere is indicated. The character
of the optic neuritis gives little information of the nature
of its cause.
Etiology and Pathology. — The largest number of
cases of well-marked optic neuritis arise in connection
with organic disease of the brain and its membranes. It
occurs at some time in 90 per cent, of the cases of
brain-tumor. Next in frequency comes meningitis, then
abscess, softening, thrombosis of the sinuses, hydroceph-
alus, and rarely cerebral hemorrhage. The other known
causes are syphilis, rheumatism, renal-vascular disease,
lead-poisoning, suppression of menstruation ; or inflam-
mation in the orbit, or in the sphenoidal or ethmoidal
sinuses. It may be associated with the dropping- of
watery fluid from the nostril, and has been provoked by
surgical treatment of the nasal passages.
Optic neuritis may be caused by extension of inflam-
mation from contiguous parts ; and certain poisons cap-
able of similarly affecting other nerves can cause optic
neuritis. But its connection with intracranial disease is
not so clear. The chief hypotheses account for its causa-
tion by intracranial pressure acting through the ophthal-
mic vein, or acting through the lymph-channels surround-
ing the nerve, and especially at the point where the
central vein of the retina emerges from the optic nerve.
Direct extension of the inflammation from within the
cranial cavity has been assumed as the explanation,
although microscopical evidence of such a process through-
out the nerve-trunk has often been lacking. The trans-
390 PATHOLOGY OF OPTIC NEURITIS.
mission through the lymph-channels of chemical substances
capable of exciting inflammation, or of morbid influences
through vasomotor or trophic nerves, have also been sup-
posed to l>e the active agencies in causing optic neuritis ;
but of the relative value and correctness of these various
hypotheses, we cannot at present judge.
Treatment. — The essential point is the removal of the
cause of the neuritis. Where the cause is local, radical
local measures should be resorted to. Removal of an
intracranial growth, or even relief of intracranial press-
ure without excision of a growth, is commonly followed
by prompt improvement. Syphilis should be combated
by the energetic administration of mercury and of
potassium iodid. Non-syphilitic optic neuritis is to be
met by large and increasing doses of potassium iodid,
maintained near the limit of the individual tolerance.
The eyes should be allowed to rest, and should be pro-
tected from excessive light or sudden changes of illu-
mination. Tapping the sheath of the optic nerve just
back of the eyeball, reaching it from the temporal side,
has been tried with doubtful benefit.
Prognosis. — The prognosis in optic neuritis depends
upon its cause. When it arises from incurable cerebral
disease, it passes on into optic atrophy and blindness.
When it arises in connection with acute curable disease,
complete recovery with full vision is possible. The pros-
pect is not good for regaining sight already lost, except
in those cases of monocular neuritis, arising from rheu-
matism, cold, or local disease in the orbit or neighboring
bones or cavities. Rapid loss of sight in chronic neuritis
is unfavorable. Narrowing of the visual field is more sig-
nificant of progressive loss of sight than is impairment
of central vision without contraction of the field.
Optic neuritis gives little indication regarding the issue
of the disease causing it, although a severe chronic neu-
ritis points to the continuance and probable progress of
its cause. In many cases of cerebral disease it appears
as a late symptom. But sometimes it appears early, and
very slowly progresses and passes on to atrophy.
DISEASES OF THE OPTIC NERVE. 391
Retrobulbar Optic Neuritis (Orbital Optic Neu-
ritis).— There occur rare cases of rapid impairment of
vision in one eye, with pain in and about the orbit, sore-
ness on moving the eye, and tenderness when the eyeball
is pressed back into the orbit. With the ophthalmoscope
the nerve-head, at this time, appears normal or but
slightly swollen and hazy. But after several weeks or
months if sight is permanently damaged, the signs of
optic atrophy may appear. The impairment of vision
generally affects only one part of the visual field, or
affects some parts more than others.
Usually the disease runs an acute course ending with
partial or complete recovery of vision. It is not espe-
cially significant of cerebral or general diseases. It has
the same causes as peripheral neuritis affecting other
nerves : as extension of local inflammation, cold, rheuma-
tism, syphilis, alcoholic and other poisons, and acute infec-
tious diseases. It may also attend chronic degenerative
disease of the central nervous system.
The treatment is the removal or treatment of the cause,
with local blood-letting at an early stage. Later potas-
sium iodid may be given, and still later strychnin. The
prognosis should always be guarded, but recovery may
occur even after several months.
A chronic retrobulbar neuritis is generally regarded as
the lesion in toxic amblyopia. The disease is considered
under the later name (see page 397).
ATROPHY OF THE OPTIC NERVE.
Optic nerve atrophy (Optic Atrophy or Degenera-
tion of the Optic Nerve) is characterized by impairment
of vision, contraction of the field of vision, pallor and
shrinking of the nerve-head as seen with the ophthalmos-
cope, and in some cases marked diminution in the size of
the retinal vessels.
Symptoms. — The failure of vision may be rapid when
the atrophy supervenes upon optic neuritis ; but in other
cases is usually slow, sometimes continuing progressive
392
SYMPTOMS OF OPTIC ATROPHY.
for years. The patient may complain of a cloud or mist
before him. The progress is sometimes rather rapid, at
others the condition may seem stationary. There may be
days when the patient believes his sight improving. The
earliest positive symptom is marked contraction of the
field of vision, first for colors and then for form. The
contraction of the color-fields may go on to complete
obliteration, usually in the order of their size, so that the
patient becomes blind first for green, then red, and later
for blue.
The appearance of the nerve-head is that of anemia.
FIG. 125.— Optic atrophy consecutive to neuritis, left eye. The disk is
dead-white, slightly depressed, and surrounded by a ring of atrophied and dis-
turbed choroid. The retinal vessels are somewhat irregularly narrowed.
The swelling caused by optic neuritis loses its red, becom-
ing paler and gray, or the pink of the normal disk gives
place to a white or gray color; and small visible vessels
become fewer. The margin of the disk, at first hidden
in retinitis or neuritis, slowly becomes more distinct,
DISEASES OF THE OPTIC NERVE. 393
losing even the slight blurring above and below, which is
caused by the passage of the thick layer of normal nerve-
fibers across it. The shrinking of the nerve does not
usually cause diminution in the choroidal opening; and
a scleral ring may appear within it, around the shrunken
nerve-head. The shrinking is most manifest in the
depression of the nerve-head, described on page 97, in
which depression the normal excavation usually dis-
appears (see Fig. 31). The diminution of the retinal
vessels, may at first only affect the arteries (after neuritis) ;
or may be a very gradual shrinkage of both arteries and
veins. It may be absent, the retinal vessels appearing
quite normal. (Compare Fig. 125 and Plate II, 9 with
plates and figures representing the normal disk.)
Causes. — Optic atrophy is caused by optic neuritis,
and therefore by most of the causes of neuritis. It
follows certain forms of retinal diseases, especially syphil-
itic chorioretinitis, pigmentary degeneration, embolism
and thrombosis. It may also be caused, apart from neu-
ritis, by syphilis, venereal and other excesses, impaired
nutrition in old age, acute infections diseases, chronic
poisoning, malaria, or diabetes. Laceration of, or direct
pressure on the optic chiasm or optic tract by broken bone,
hemorrhage, or new growths, may cause it. A very im-
portant class of cases arise in connection with spinal
sclerosis and general paralysis of the insane. [See Plate
II, Fig. 10.] The optic atrophy may be the earliest lesion,
appearing years before the impairment of locomotion. In
rare cases optic atrophy is hereditary, appearing in early
life, usually soon after puberty, in several of the males
of successive generations. It is probable that disturb-
ances of circulation due to high altitude are sometimes
a factor in causation. Some cases must still be called
idiopathic.
Varieties. — Atrophy occurring without antecedent
disease of the optic nerve or retina, as from impaired
nutrition, or with spinal sclerosis, is called primary
atrophy. It is marked by increased distinctness of the
details of the optic disk, as the margins and lamina crib-
394 VARIETIES OF OPTIC ATROPHY.
rosa, while the adjoining portions of the choroid appear
unaltered. The color of the nerve-head is usually gray.
The retinal vessels long remain of normal size, or are but
slightly diminished. The narrowing of the visual field is
usually regularly concentric. Primary atrophy is com-
monly bilateral.
Secondary optic atrophy is a term often restricted to
cases not following neuritis, as those occurring from pres-
sure upon the optic tracts. The color of the disks is
white, or rather gray, as in primary atrophy, and the
disk-margins distinct. The visual field is liable to show
scotomas, or irregular interruptions, the exact character
of which depend on the special cause of the atrophy.
Consecutive atrophy (neuritic, post-neuritic, or post-
papillitic, retinitic^or choroiditic atrophy) is atrophy fol-
lowing optic neuritis, or retinal, or choroidal diseases, as
a later stage in a continuous process. In post-neuritic
atrophy the disk-margins may at first be quite hidden,
and the nerve-head swollen, but of a pale gray color.
Slowly the swelling passes into excavation, the disk-
margins become more distinct, and the color a more dead
white. The retinal veins are at first large, but gradually
shrink until they bear nearly the normal proportion to the
shrunken arteries. The nerve-head is opaque, the lamina
is hidden. The choroid about the nerve-entrance is more
or less atrophic, with specks and blotches of pigment-
accumulation. Often the area of disturbed and partly
atrophied choroid forms an irregular ring around the disk.
The walls of the retinal vessels are somewhat thickened
and opaque. Gray or white streaks extend on either side
of the principal vessels beyond the margin of the optic
disk. The field of vision is narrowed, the boundary
being often marked by irregular re-entering angles.
Retinitic or choroiditic atrophy may start with slight
haziness of the disk, which remains opaque, but not
hidden by an opaque swelling ; its color is yellowish. The
retinal vessels become contracted, sometimes extremely
narrow. The choroid about the disk shows no greater
alteration than in other parts of the fundus. The form
DISEASES OF THE OPTIC NERVE. 395
of the field is often affected by the distribution of the
retinal lesions.
Simple atrophy is primary atrophy, or secondary
atrophy, presenting similar appearances. White
atrophy and gray atrophy are so called on ac-
count of the color of the disk. This depends partly on
other factors, but tends to white when there is a marked
increase of the interstitial connective tissue of the nerve-
head, and to gray when there is atrophy of the nerve-
fibers without increase of connective tissue.
Diagnosis. — The difficulties of deciding whether an
optic disk is abnormally pale have already been discussed
on pages 96 and 384. While the ophthalmoscopic appear-
ances of advanced atrophy are usually quite striking, it
is always prudent to carefully ascertain the acuteriess of
vision and the extent of the visual fields before making
a diagnosis. Care must be taken to exclude other condi-
tions, as errors of refraction or opacities of the media,
that would impair central vision ; or detachment of the
retina that might be the real cause of a limitation of the
field of vision. Very striking appearances of atrophy
may exist with full acuteness of vision, or a normal field.
Treatment. — In the early stages the vigorous treat-
ment of the cause is most important. Later the use of
strychnin in ascending and full doses, either by the
mouth or hypodermically should be tried, and persisted
in for some months. Nitroglycerin may prove of value ;
and inhalations of nitrite of amyl repeated every day or
two have seemed to benefit. Strict attention to the gen-
eral health comes nex't in importance, and change of
residence, especially change of altitude, may be tried, if
practicable. The whole list of "alteratives" have been
given without showing marked influence, the iodids offer-
ing most hope of benefit. Galvanism lias been ad-vocated ;
but its efficacy is doubtful.
Prognosis. — In primary atrophy this is extremely
grave. The atrophy usually goes on slowly to complete
blindness. The prognosis is altogether bad when second-
ary atrophy succeeds a lesion that has already caused
396 PROGNOSIS OF OPTIC ATROPHY.
blindness. In consecutive atrophy when the neuritis has
been due to a continuous progressive cause, brain-tumor,
little is to be hoped. In other cases of secondary and con-
secutive atrophy the prospect is better ; but generally the
most that can be hoped for is to retard or check the
deterioration of vision. In some cases of atrophy follow-
ing acute disease, and with the toxic amblyopias, positive
improvement of vision or complete restoration are to be
hoped for. The optic disk may be very pale and con-
tinue so, and yet great improvement of vision may be
brought about. The vision in the periphery of the field
gives the most valuable prognostic indication. If the
field is progressively narrowing, even though central
vision may be unaltered, the outlook is gloomy. If the
field of vision is mft narrowed, even though central vision
is greatly impaired, one may hope for improvement.
OTHER ORGANIC CHANGES IN THE OPTIC NERVE.
Hyaline bodies in the nerve-head (Drusen) are
small, translucent, rounded, multiple masses, partly or
wholly hiding the nerve-head. They are rare and are
found mostly in eyes that have suffered serious damage
from disease of the optic nerve, retina, or choroid ; but
they have been noted in eyes otherwise apparently
normal.
Tumors of the Optic nerve are rare. They are
generally benign myxomas or fibromas. They develop
behind the eyeball, usually begin in childhood, with im-
pairment of vision that may not be noticed until, without
pain, the eye begins to protrude, being pushed directly
forward or a little downM-ard. The ocular movements
remain remarkably good for so much protrusion. The
growth of the tumor is very slow. With the ophthal-
moscope, some cases show7 optic neuritis, sometimes with
great swelling and obstruction of the retinal vessels.
This may give place to atrophy, with great narrowing
of the vessels.
The growth should be excised as soon as recognized.
DISEASES OF THE OPTIC NERVE. 397
Sometimes this can be done without removal of the eye ;
but in most cases the eye, which is always blind, has been
enucleated with the tumor. There is little tendency to
recurrence.
Coloboma of the optic nerve or its sheath has
already been sufficiently described (page 98).
TOXIC AMBLYOPIAS.
Many drugs are capable of causing impairment of
vision ; but with only a few are the effects so frequent, so
characteristic, and so directly connected with lesions of the
retina and optic nerve as to merit consideration here.
Two very distinct types of toxic amblyopia are easily
recognized, the one most frequently associated with the
prolonged use of tobacco, the other best understood as
arising from excessive doses of quinin.
Tobacco Amblyopia (Amblyopia ex abusa, Central
Scotoma, Rctrobulbar Neuritis). — This form of amblyopia
occurs once in from 500 to 1000 cases of eye-disease. It
is unknown in childhood, very rare among young men,
and among women. The best recognized lesion is a de-
generation of certain parts of the optic nerve, the papillo-
macular bundle, including the fibers coming from the
macula entering at the disk, at the lower outer part of
the nerve, and becoming central in the nerve-trunk about
the optic foramen. It is possible, however, that the
changes in the optic nerve are secondary to changes in
the retina.
Symptoms. — Attention is first attracted by impaired
vision, there being a mistiness at the center of the field
that obscures the object looked at. This is more trouble-
some in a bright light, varies a good deal from time to
time, and may increase so fast as to interfere with
ordinary eye-work in a very few days. Usually both
eyes are similarly affected. In rare cases, but one may
suffer. Careful testing always reveals a central color-
scotoma for green and red, sometimes very small, but
in other cases extending from around the fixation-point
398 TOBACCO AMBLYOPIA.
toward and sometimes including the blind-spot. Some-
times all colors are confused within the central scotoma,
or the whole field for green or red may be swallowed
up, rendering the patient quite color-blind. In bad and
chronic cases the scotoma may become absolute, light-
perception being lost in the center of the field. In a
few cases there is some narrowing of the periphery of
the visual field ; but this must be regarded as rather acci-
dental, and not a usual symptom of the disease.
The ophthalmoscope gives no certain evidence as to the
presence of the disease in the early stages. The disk
sometimes appears slightly hazy and a dirty red, but this
is not marked or characteristic. Late, in bad cases, the
atrophy of the affected nerve-fibers, with proliferation of
connective tissue, causes the outer, or lower outer, quad-
rant of the disk to become pale gray or even greenish.
The course of the disease is essentially chronic. The
disturbance of vision often continues to get worse for
weeks or months, the patient being beguiled by the days
of improvement to hope for recovery, or seeking relief
at the optician's by changes of glasses. Finally, the
condition becomes stationary, or, under proper treatment,
vision slowly improves or returns to normal.
Causes. — Tobacco may cause this disease in whatever
way it gains entrance to the system, though the larger
number of cases are due to smoking. The amount re-
quired varies greatly with different persons ; amblyopia
sometimes begins after the amount used has been greatly
diminished from what was habitual when the patient was
younger. The manner of using, as smoking before meals,
the kind of tobacco, and racial predisposition, all influence
the liability to the disease. Besides the prolonged ex-
posure to tobacco and the influence of age, causes of
impaired general nutrition help produce the disease. It
often arises after a severe nervous shock, or special men-
tal depression or emotional strain, and may accompany
impaired digestion, " tobacco heart," impaired power of
concentrating the mind, or sleeplessness.
Diagnosis. — The history of variable fogging of central
TOXIC AMBLYOPIAS. 399
vision, not improved by glasses, and the central scotoma
for red and green are characteristic. It only remains to
find if the cause be the use of tobacco or of some other
toxic agent, or whether it is hereditary atrophy or chronic
retrobulbar neuritis from cold, or attending spinal scle-
rosis. In the latter cases there is more general involve-
ment of the field of vision than in tobacco amblyopia,
especially contraction of the periphery, which may be
quite irregular.
Treatment. — The first point is the complete avoidance
of tobacco in every form, and of all other substances,
especially alcohol, liable to cause the same lesions. Next
every means should be employed to restore the general
health of the patient, as sleep, good food, and relief from
strain. If the case is seen while the impairment of vision
is increasing, potassium iodid should be given in moderate
doses for two or three weeks. But the special remedy is
strychnin, in increasing doses, until marked improvement
begins or the limit of tolerance is reached. Then the
dose arrived at should be continued until recovery is
complete, or, with intermissions of a week or two, for
many months. Inhalation of nitrite of amyl will often
cause marked temporary improvement in vision ; and
the internal use of nitroglycerin may improve it more
permanently.
Prognosis. — If the case is seen within the first few
weeks, and the patient will abstain entirely from the use
of tobacco and alcohol, complete recovery can generally
be brought about, and may occur without other treat-
ment: Great reduction in the consumption of these two
narcotics may be followed by practical recovery, but this
is much less certain. Persistence in their use is pretty
sure to lead to great impairment of vision or practical
blindness, although complete blindness (through optic
atrophy) is rare. Even after complete recovery, the
lower outer quadrant of the disk may continue very pale.
The disease sometimes recurs if the use of tobacco is
resumed.
Alcohol amblyopia (amblyopia ex abusa) is essen-
400 ALCOHOL AMBLYOPIA.
tially the same disease as tobacco amblyopia. In a very
large proportion of cases it is the joint action of the two
poisons that causes the disease, but either alone is capable
of causing it. The influence of alcohol may be sometimes
traced, in the occurrence of the amblyopia at an earlier
age, in a greater tendency to permanent lesions, and in
liability to run into complete atrophy.
Methyl alcohol (wood-alcohol) drunk to intoxication
sometimes causes blindness. Recovery may occur, or
there may be temporary improvement of vision, followed
after several days by progressive loss of sight and optic
atrophy. The treatment has included pilocarpin sweats
and large doses of potassium iodid. Strychnin may be
used in the later stages.
lodoform atnblyopia occurs in a few cases after the
prolonged use of iodoform dressings to large raw surfaces
from wounds or burns, or the internal administration of
large doses of the drug. Its onset is accompanied by
other symptoms of iodoform poisoning, fever, a rapid,
soft pulse, diarrhoea, headache, delirium, disturbed sensa-
tions, or stupor. In the best reported cases the visual
disturbance was in the main similar to that of acute
tobacco amblyopia. The diagnosis would be based on
the presence of these symptoms with a history of the use
of iodoform. The treatment is the same as for tobacco
amblyopia, beginning with the removal of the toxic in-
fluence; and the prognosis is equally favorable.
Bisulphid of carbon atnblyopia occurs among
workmen who inhale the vapor of this substance as used
in the process of vulcanizing rubber. The general symp-
toms of the poisoning are, at first, vertigo, irritability, and
excitement, and later, dejection, loss of memory, cutan-
eous anesthesia, and muscular weakness and atrophy.
The amblyopia is very similar to that produced by to-
bacco. It is to be treated in the same way, the important
point being the avoidance of the continued inhalation of
the fumes of the poison.
Nitroben^jol, used in making certain explosives and
perfumes, causes amblyopia among those who work ex-
TOXIC AMSLYOPIAS. 401
posed to its fumes and dust. The general symptoms
include headache, muscular weakness, cyanosis, and men-
tal disturbance. The disturbance of vision closely re-
sembles that of tobacco amblyopia, except that there is
also contraction at the periphery of the field of vision.
The pupils are dilated, and with the opththalmoscope the
eye-ground and vessels appear strikingly darker than
normal, and the retinal veins large and tortuous. The
treatment resembles that for tobacco amblyopia, and the
prognosis is good if the patient can escape further ex-
posure.
Quinin Amblyopia (Quinin Blindness). — Quinin, and
in larger doses the other cinchona alkaloids, have the
power of causing a characteristic, temporary or permanent
disturbance of the visual apparatus. Twelve or fifteen
grains of the drug in divided doses has produced marked
temporary amblyopia ; but the causative dose has usually
been very large, often several drams.
Symptoms and Course. — General symptoms of quinin
poisoning, as deafness, ringing in the ears, fulness of the
head, headache, and unsteadiness of gait, and sometimes
visual hallucinations, precede the amblyopia, which may
be deferred for days. When it comes, the onset is
often very sudden, and in bad cases the blindness be-
comes absolute. This absence of light-perception may
last from a few hours to several weeks. The pupils are
widely dilated. The ophthalmoscope shows great dimi-
nution of the retinal vessels, extreme anemia of the disk,
and sometimes a slight general opacity of the retina, with
a red-spot in the macula resembling embolism of the
retinal artery.
After a time vision for form returns. So soon as it
can be investigated, the visual field is found greatly con-
tracted and color-blind. Gradually vision improves and
color-perception returns, usually to a narrowed field. The
optic disks remain white, the retinal vessels greatly con-
tracted. Cases have been reported as quinin blindness
with a central scotoma, and without contraction of the
visual field. Their true nature is doubtful.
26
402 QUININ BLINDNESS.
Diagnosis. — Quinin blindness might be taken for reti-
nal embolism or thrombosis ; but these attack but one
eye, while quinin amblyopia affects both.
Treatment. — The administration of quinin must be
stopped, and bromids or hydrobromic acid may be given
internally. Inhalations of nitrite of amyl should be tried
cautiously during the first few days. Strychnin is to be
given hypodermically or in ascending doses by the mouth.
Prognosis. — All recorded cases have recovered some
sight, although in one it was only ability to count fingers.
But after complete blindness even of very short duration
there will remain some permanent impairment, especially
contraction of the visual fields ; and patients who have
once suffered in this way are liable to relapse after com-
paratively small dpses of the drug.
Salicylic acid and sodium salicylate in large doses
sometimes cause amblyopia quite like that produced by
quinin. It should be similarly treated.
Acetanilid can also cause temporary blindness with
retinal anemia, which should be treated with nitrite of
amyl and strychnin.
The use of a strong alcoholic preparation of Jamaica
ginger as an intoxicant has been quickly followed by
blindness, which was to a great extent permanent.
Filix mas sometimes causes amblyopia, but its effects
have not been well studied.
CONGENITAL, HYSTERICAL, AND SIMULATED AMBLY-
OPIAS.
Amblyopia, or weakness of sight, may properly be
restricted to cases in which there is no discoverable
cause for the impairment of vision ; and amaurosix to
cases of blindness with equal absence of ascertainable
lesions. We have used the term toxic amblyopias in con-
nection with the effects of certain poisons, because the
essential lesions by which they may ultimately be class-
ified are not yet established. A few other conditions still
remain that are classified as amblyopias.
AMBLYOPIAS. 403
Congenital amblyopia of one eye, or chiefly affect-
ing one eye, is often a factor in the production of squint.
Less frequently it exists without any fault of the ocular
movements. It may affect the whole field of vision or
take the form of scotoma. It may be regarded as an
arrest of development, which might occur after birth,
since probably vision is then only imperfectly developed.
Amblyopia from imperfect focussing- of the light
upon the retina may be regarded as similar to congenital
amblyopia, except that until quite late in life vision is
still capable of marked improvement. It is best studied
in cases of high astigmatism, in which the giving of the
most accurate correcting lens will at first leave vision quite
imperfect. But with the wearing of the correcting lens
vision improves, at first rapidly, then more slowly, until
after many weeks or months it may in young persons rise
to normal.
Congenital color-blindness may also be regarded
as a special form of congenital amblyopia, although it
shows no tendency to association with other congenital
anomalies affecting vision. It has been sufficiently dis-
cussed (page 49). It should always be excluded before
regarding impaired color-perception as a symptom of
disease.
Hemianopsia, sector defects, and scotomas
with transient amblyopia are sufficiently considered
in relation to diagnosis in Chapter II, and in Chapter
XX. In so far as they are not due to lesions of the eye
or optic nerve, they are really symptoms of brain disease.
Hysterical amblyopia and simulated ambly-
opia, although probably not the same thing, are to be
detected by the same tests ; and may here be considered
together. The first step in every case is by a thorough
objective examination, including the use of the ophthal-
moscope, skiascopy, oblique illumination, and careful ob-
servation of the eye movements, to exclude all errors of
refraction or ocular diseases, or to recognize their share in
the symptoms.
Tests. — When amblyopia of but one eye is alleged, the
404 HYSTERICAL AMBLYOPIA.
best tests are those which exclude the " seeing " eye with-
out the knowledge of the patient. This may be done
(Harlan's test) by placing a pair of trial frames upon the
patient, with the correcting lens before the " blind " eye,
and before the " seeing " eye a strong concave or convex
spherical lens. Or (the author's test) two strong cylin-
drical lenses may be placed before the "seeing" eye,
which when turned a certain way will give the optical
effect of its correcting lens. The patient having been
convinced that he can see through these lenses, one of
them is turned without his knowing it so that he can see
nothing through them, and what he reads is known to be
seen with the "blind" eye. These tests enable one to
ascertain exactly the vision of the "blind" eye.
As another test* the patient may be made to look with
the stereoscope, at a picture, or at a word, part of which
is seen by one eye and part by the other. Recognizing
the whole word or describing both parts of the picture,
proves vision with both eyes. Again, the patient may
be induced to read colored letters through colored glasses,
the glass before the " seeing " eye being of the color com-
plementary to that of the letters, and rendering them
invisible to it. With any of these tests one may by cov-
ering the alleged blind eye interrupt vision, and demon-
strate to the patient or to a third party that it was
the " blind " eye that saw.
The holding of a 5 centrad prism before one eye, with
the base up or down, produces such a vertical displace-
ment of the retinal images that the patient cannot " over-
come " it by turning the eye to a corresponding extent ;
and, if both eyes see, causes a vertical diplopia. By
holding the prism before the " seeing " .eye, the patient
will usually say that it makes a lamp-flame look double,
not knowing that this proves vision in the other eye
also.
The above tests may be defeated by the patient closing
the " blind " eye and so recognizing that the other is ex-
cluded from seeing, or that, with the prism one image
disappears.
AMBLYOPIAS, 405
A test that is harder to demonstrate to others, and
which does not give the exact acuteness of vision of the
blind eye, but which nothing but violence preventing its
application can defeat, is the objective test with prisms.
If a prism of 6 or 8 centrads is placed before one eye
with its base to the temple, the eye with sufficient vision
involuntarily turns slightly toward the nose, to restore
the correspondence of the retina to the images formed
upon it. No effort of the patient's will can prevent this
movement.
When blindness of both eyes is claimed, the last test is
still applicable. The corresponding movement, as the
prism is placed or withdrawn, shows with certainty the
existence of vision sufficient to perceive diplopia, probably
equal to at least one-twentieth of the normal standard. The
reaction of the eyes to this test in the different possible
cases are : If both eyes see, the eye before which the
prism is placed moves, the other remains fixed, or makes
a very slight tremulous movement ; if one eye sees, and the
other is blind, the prism before the seeing eye causes both
to move equally, while before the blind eye it causes
neither to move ; if both eyes are blind, the placing and
withdrawing of the prism cause no motion.
When it is claimed that both eyes are weak, but not
blind, the vision should be tested with various test-types
at different distances, care being taken that the focussing
shall be equally good at all distances, so that the acuteness
of vision should really be the same. The patient who reads
the 40-meter type at 4 meters, can read the 2-meter type
at 20 centimeters. The patient with vision really imperfect
will do this. But with hysterical or simulated amblyopia,
tests at different distances will show great discrepancies.
The patient's vision is really at least as good as the
best vision admitted for any distance. The above tests
are generally more practical and more conclusive and
exact than the older method of placing the patient thor-
oughly under the influence of ether and noting the
evidences of vision during the period of recovery.
Hysterical amblyopia may also be marked by hemianop-
406 HYSTERICAL AMELYOPIA.
sia or other limitations of the field of vision, especially
a variable concentric narrowing ; or there may be color-
blindness or reversal of the order of the color-fields.
Developmental Alexia (Congenital Word Blindness)-
— Although not a disease of the eye, nor strictly speaking,
a defect of sight, the clinical recognition of it is almost
invariably by ophthalmologists. It consists in an inabil-
ity to remember or associate the symbols of language,
with the spoken sounds or their meanings. The child
may be bright, and mentally well-developed in every other
way, but quite unable to read or even to recognize the
letters of the alphabet after years of effort to learn. In
some cases, numbers and music are read normally, draw-
ing and needle- work present no especial difficulties, yet
reading of even Short, simple words may be impossible.
In most cases the deficiency is finally overcome,' the
power to read developing at a later period than usual.
Diagnosis. — Good vision may be proved by ability to
recognize figures or dots, or generally some letters that
are known, even when these are small as could be recog-
nized by the normal eye ; while other letters are not
known or only recalled by tracing them with the hand,
or words are recognized by going through the lip motions
that would be used in spelling them.
Treatment. — Children thus afflicted should not be
taught in classes with normal children. The visual mem-
ory should be developed by copying the letters, cutting
them out of paper, etc., following on the printed page
the reading of another person aloud, or writing from
dictation.
Prognosis. — In the great majority of cases, the defect
may be completely overcome by proper treatment.
DISEASES OF THE ANTERIOR CHAMBER. 407
CHAPTER XIV.
DISEASES OF THE ANTERIOR CHAMBER, CRYSTAL-
LINE -LENS, AND VITREOUS HUMOR.
THE ANTERIOR CHAMBER.
THE anterior chamber is a lymph-space of varying size,
liable to alteration of the character and amount of fluid
passing through it, to infection, and to obstruction.
Depth. — It is most shallow in early infancy from the
undeveloped condition of the eye, and in old age from the
increased size of the crystalline lens. It is deep in apha-
kia and very deep in keratoglobus, both from prominence
of the cornea and from flattening of the iris.
It is often rather deep in myopia. It may also be deep
in plastic inflammation causing shrinking of the vitreous
and retraction of the lens. It appears deeper when there
is any opacity in the cornea.
The anterior chamber is found shallow in glaucoma, in
cataract during the stage of the swelling of the lens,
during parenchymatous inflammation of the iris, or from
bellying forward of the iris after exclusion of the pupil.
After injury of the eye it may be shallow from traumatic
cataract, and is quite obliterated so long as a perforating
wound permits the free escape of the aqueous humor. In
degenerated shrunken eyes it may be very shallow. The
anterior chamber is of unequal depth in different sym-
metrical parts, from dislocation or partial absorption of
the lens, unequal swelling of the iris, or partial synechia.
Alterations of the aqueous humor occur in all
cases of inflammation of the ciliary body and iris. Tur-
bidity of the aqueous is then a cause of impaired vision,
and may be made out by careful oblique illumination. In
some cases a gelatinous exudate occupies a large part of
the chamber (spongy iritis). Hypopyon has been described
(p. 290) in connection with corneal suppuration, one of
its causes. The anterior chamber may contain crystals of
cholesterin.
408 DISEASES OF THE ANTERIOR CHAMBER.
Hyphemia, or blood in the anterior chamber, appears
of a dark -red color, usually as a distinct mass in the lower
part of the chamber. It may come from the conjuuctival
limbus, during operation, or from the iris or deeper parts
of the uveal treat from either injury or disease. The
mere presence of blood in the anterior chamber is not of
serious importance. It is grave only as a symptom of the
cause of the hemorrhage, or of the impaired nutrition of
the eye. When the general nutrition of the eye is perfect,
as in cases of simple injury, the hyphemia may be removed
very rapidly, a mass occupying the greater part of the
chamber disappearing in a few hours. But in certain
diseased conditions, as in chronic glaucoma, a small
amount of blood may remain without perceptible diminu-
tion for weeks.
Infection of the anterior chamber gives rise to iritis
or keratitis. Obstruction is considered in connection
with glaucoma, which it causes. Cysts and other tumors
of the iris grow into the anterior chamber ; and it may also
contain a foreign body, cysticercus, or filaria.
DISEASES OF THE CRYSTALLINE LENS.
Cataract. — The most constant and obvious symptom
of disease of the crystalline lens is opacity, so that nearly
all such diseases come under the term cateract. Cataract
has been recognized to include any opacity of the crystal-
line lens or its capsule. But the term has gained popular
currency almost wholly in connection with those cases in
which an extensive opacity prevents or impairs vision.
Hence its use in addressing the laity should be restricted
to that meaning, or accompanied by an explanation of its
more inclusive definition.
Alterations of the I/ens by Age. — Changes of con-
sistence are described in connection with accommodation
and presbyopia, pages 124 and 144. Changes of size are
taken up in connection with glaucoma (Chapter XV) ; here
changes of transparency are alone referred to. The crys-
talline lens is never perfectly transparent. In childhood
CRYSTALLINE LENS. 409
by illuminating the dilated pupil very obliquely from one
side, and looking at it very obliquely from the other side,
one may see a faint gray reflex from the anterior surface
of the lens, the most striking portion having the form of
a star, the branches of which correspond with the lens-
sectors. With increasing age this reflex becomes more
dense, until in many elderly persons the appearance of the
pupil by ordinary illumination is quite that of gray
opacity of the lens, although the lens and the patient's
acuteness of vision may be quite normal. But in addition
to this general loss of transparency, age is attended with
a great liability to distinct localized opacities of the crys-
talline lens. The writer noted such opacities in 77 out of
100 patients upward of 75 years of age. Yet such opaci-
ties are not sufficiently constant to be regarded as a
necessary or entirely normal senile change.
Senile Cataract (Hard Cataract}. — The usual associa-
tion of age with common forms of cataract justifies the
term " senile cataract," while the increasing rigidity and
size of the nucleus which also accompanies age, gives
occasion for the term " hard cataract," in contradistinction
to " soft cataract," or opacity occurring in a lens which
has no hard nucleus.
Symptoms and Course. — The only symptom noticed
by the patient is impairment of vision. This comes on
gradually, sometimes so gradually that in one eye useful
vision may be entirely lost before any impairment is
noticed. In other cases after a few weeks or months of
rapid loss of vision, it may remain unchanged or even
notably improve. The whole field of vision is equally
affected, there is no narrowing at the periphery of the
field, and color-perception remains relatively good. When
the opacity is not distributed equally throughout the
lens, the acuteness of vision may vary, being in one case
better in a feeble light, and in another case better in a
strong light. The impairment of vision in some cases
never goes so far as to prevent the counting of the fingers
held a few inches before the eye ; but in others, the
patient may find it difficult to recognize the direction in
410 SENILE CATARACT.
which the hand is moved before the eye, or the direction
in which a lighted candle is held before it. Light-per-
ception always remains.
The impairment of vision may at first be due to chaiif/^x
in the refraction of the lens, rather than opacity. This
may be an increased refraction at the nucleus, causing
myopia with the pupil contracted, or negative aberration
when the pupil is dilated. This myopia may enable the
patient to read without the convex lenses on which he
has long been dependent, and hence is called second *//////.
But it causes a corresponding diminution of distent
vision, and often there is enough opacity of the lens
attending it to diminish near vision also. In other eyes
the refractive change produces irregular astigmatism,
which causes sectors of light and shadow that resemble
cortical opacities of the lens, and which appear when the
light is thrown into the eye from the ophthalmoscope
mirror, held at some little distance as in skiascopy. This
disturbance of refraction often causes marked monocular
polyopia, especially when the pupil is dilated. The
patient sees at night several moons overlapping each
other, or sees a point of light, like a distant electric light,
broken into several separate irregular lights, differing
from each other in the direction of their rays.
Objectively, cataract is to be studied with oblique illumi-
FIG. 126.— Cortical cataract. A, section of lens showing position of opacities.
-B, appearance of dilated pupil by oblique illumination. C, appearance \vith
the ophthalmoscope.
nation and the ophthalmoscope. By the former the opacity
appears as a lighter mass against a dark back-ground,
with the latter the opacity appears black against the red
fundus-reflex. (See Figs. 126-128.) The opacity may
DISEASES OF THE CRYSTALLINE LENS. 411
appear as a diffuse cloud, or as sharply limited masses
surrounded by clear lens-substauce. These masses have
to
FIG. 127.— Nuclear cataract. A, section of lens. B, appearance of dilated pupil
by oblique illumination. C, appearance with the ophthalmoscope.
most frequently the form of pyramids, spicules, or striae,
broadest toward the ciliary region, and with their apices
pointing toward the center of the pupil.
Eyes in which cataract is developing, generally show
evidences of eye-strain, as pain after use, redness of the
optic disk, or conjunctival hyperemia. In some cases the
eye-strain must be regarded as a cause of the cataract, in
others it is an effect of the increasing difficulty of vision.
Patients suffering with cataract find a bright light annoy-
ing, because of the diffusion caused by its shining on the
lens opacity.
The stages through which cataract usually passes when
the patient lives long enough are :
Incipient cataract, while the opacity is still partial,
and portions of the pupil still remain clear enough to
give useful vision.
Swotten cataract, when the opacity has become more
general but is still not complete. The lens at this stage
is markedly swollen by imbibition of fluid, and pushes
forward the iris, making the anterior chamber shallow.
Mature cataract, when the whole lens has grown
opaque, and has returned to about its normal volume.
Hypemnature cataract, when the lens is shrunken,
hard, sometimes partly calcareous, and often its capsule,
thick, tough, and thrown into ridges or folds. In a very
few cases, a senile cataract has undergone spontaneous
absorption, or has become dislocated out of the line of
vision, with a restoration of sight.
412 SENILE CATARACT.
Varieties. — The above different stages are spoken of
as varieties. In addition, we may recognize in the earlier
stages varieties based on the location of the opacity, thus :
Nuclear cataract is opacity of the lens-nucleus, gener-
ally appearing as a diffuse clouding, most dense behind
the center of the pupil. It is illustrated in Fig. 127.
Cortical cataract is the term applied to cases present-
ing opacities in the lens-cortex. At first there are isolated
needles or spicules of opacity, situated in either the an-
terior or the posterior cortex or in both. They are
usually larger and more numerous in the lower nasal
quadrant of the lens than in any other portion. Their
distribution and appearance are illustrated in Fig. 126.
Cortical is the most common form of senile cataract. In
the early stages, » case may be purely cortical or entirely
nuclear; but, in most cases of nuclear cataract, some
opacities may be found in the cortex, and always the cor-
tex becomes somewhat opaque before maturity.
Choroidal cataract is the term applied to cases in
which choroidal disease is followed by a very slowly
developing, diffuse nuclear opacity, of a decidedly brown
color. The nucleus is very brown and hard, and the
opacity often remains so incomplete that some vision is
retained for many years. This form occurs in myopic
eyes.
Slack cataract those rare cases are called in which the
lens is a very dark brown ; so that by oblique illumina-
tion the pupil looks black, and almost normal in ap-
pearance, even when the cataract is mature.
Morgagnian cataract is characterized by a hard nucleus
surrounded by the fluid remains of the degenerated cor-
tex. The movable nucleus may be taken for a dislocated
lens, especially as the fluid in the lens-capsule is some-
times comparatively clear and there may be trembling of
the iris.
Complicated cataract is cataract in an eye that has been
the seat of other serious disease, as iritis, iridocyclitis, or
detachment of the retina. Its extraction is often ren-
dered more difficult by extensive synechias; and the
DISEASES OF THE CRYSTALLINE LENS. 413
prognosis is modified by the permanent damage the eye
may have suffered, apart from the lens-opacity.
Traumatic cataract includes all cases due to injury.
Some of these, developing slowly, present quite the char-
acters of senile cataract. The injuries of the lens are
discussed in Chapter XVII.
Diagnosis. — Partial opacity of the crystalline lens is
best recognized with the ophthalmoscope, using a strong
convex lens behind the mirror, which should be held
about the focal distance of this lens from the eye. If the
opacity be cortical, it may be concealed by the iris, unless
one looks obliquely so as to see behind the iris. In nuclear
cataract, the whole pupil may appear obscured, until by
looking obliquely the periphery of the lens is found clear.
To make a complete examination of the lens, it is often
necessary to dilate the pupil with cocain. The ophthal-
moscopic examination should never be omitted in a case
of suspected cataract ; for only thus can one avoid the
terrible blunder of allowing a patient to go hopelessly
blind with glaucoma or optic atrophy, while waiting for a
supposed cataract to ripen.
When it is ascertained that cataract is present, the
character and completeness of the opacity should be
studied by oblique illumination, especially with the bin-
ocular magnifier. The maturity of the cataract is esti-
mated by determining the depth of the opacity behind the
margin of the pupil ; usually by the breadth of the shadow
which the iris throws upon it when the light falls very
obliquely across the eye. If the whole cortex of the lens
is opaque, the opacity coining up to the level of the pupil,
the shadow is very narrow. If between the edge of
the iris and the opacity, upon which the shadow is thrown,
there remains clear lens-substance, the shadow is broad.
The two conditions are illustrated in Fig. 128.
Another indication as to the maturity of cataract is
found in the peculiar mother-of-pearl luster of the surface
of the lens under oblique illumination, which is seen
when the superficial cortex begins to be affected but has
not become fully opaque. Complete opacity is shown by
414 DIAGNOSIS OF CATARACT.
a comparatively uniform white or gray appearance of the
whole pupil.
When the question of an operation comes to be de-
cided, care must be taken to exclude, as far as possible,
other lesions, such as optic atrophy or detachment of the
retina, which would render operation useless. This is
done by testing the field of vision, and the ability to tell
FIG. 128.— Senile cntaiart. A, partial, K, mature, as seen by oblique illu-
mination, the source of light being on the left. A shows the broader shadow.
the direction of a light, (tight-projection) by holding a
candle, or the ophthalmoscopic mirror in different direc-
tions before the eye ; and by testing the quantitative light-
perception by turning a light-flame up and down, or by
holding the candle-flame or the ophthalmoscopic mirror
at different distances.
Causes and Pathology. — Beyond a general connection
of cataract with certain factors, as age, diabetes, or dis-
ease of the uveal tract, but little is known of the cause
of lens-opacity. Exposure to heat may cause it. This
is most striking in the case of glass-blowers. Heredity is
a recognized factor. Exhausting disease will hasten the
development of cataract. So will any extensive disturb-
ance of assimilation. Cataract has followed epidemics of
ergotism ; and experimentally cataract has been produced
in the lower animals by feeding with naphthalin.
Diabetic cataract is clearly dependent upon diabetes.
It usually presents a diffuse clouding of the lens, which
may grow worse, or better, with the general condition of
the patient. The connection of cataract with chronic
Bright's disease is uncertain. Chronic dyspepsia seems to
predispose to it; and tetany has been observed to be
followed by it.
DISEASES OF THE CRYSTALLINE LENS. 415
Traumatic cataract becomes opaque by the imbibition
of aqueous humor, which separates the lens-fibers and
destroys the refractive uniformity of the lens. At first,
in ordinary senile cataract, spaces form between the lens-
fibers, especially at the junction of the nucleus and cor-
tex, and at the periphery of the lens. Later, the lens-
fibers themselves become irregular and disintegrated.
Treatment. — The management of immature or incip-
ient cataract is a matter of more general interest than the
extraction of mature cataract, and is of equal practical
importance. The first point is to remove eye-strain.
Even if this has not been a primary cause of the lens-
opacity, it arises as vision becomes impaired, and influences
the eye unfavorably. If the eye is still capable of useful
vision, its ametropia, including often astigmatism due to
lens-changes, should be carefully corrected ; and the
glasses may require frequent changes. The patient must
be strongly urged not to use the eyes too long or under
unfavorable conditions. The impending danger of cata-
ract should be mentioned, if necessary, to enforce careful
use of the eyes. Exposure to excess of light, or heat
from fire or lamp, must be avoided. If much discomfort
is caused by exposure to bright light, dark glasses should
be worn, care being taken to see that they do not cause
eye-strain by irregular refraction. If the opacity is
nuclear, improvement of vision may be secured by keeping
the pupil partly dilated with weak atropin solution, instilled
every second or third day. If the opacity is chiefly in
the peripheral cortex and the center of the lens is clear,
the annoying diifusion of light can be reduced by keeping
the pupil contracted with a solution of pilocarpin, 1 : 500,
instilled every morning, or twice daily. The general
health of a patient, and especially the digestive function,
should receive careful attention. The free drinking of
water seems to retard, or sometimes completely check the
advance of senile cataract.
If the patient lives, and the opacity increases, the time
comes when the removal of the opaque lens must be con-
sidered. If but one eye is seriously affected, the cataract
416 TREATMENT OF CATARACT.
should not be removed until it is fully mature ; then it
should be extracted, before it passes into a state of hyper-
maturity. Maturity is shown by complete opacity of the
cortex, disappearance of the mother-of-pearl reflex from
its surface, and reduction of the swelling, as shown by
increase in the depth of the anterior chamber to the
normal. In this condition, the cataract is most easily
extracted.
Ripening Operations. — When, however, both eyes are
affected, as soon as the better eye becomes incapable
of useful vision, so that the patient is compelled to give
up all ordinary occupations, measures should be adopted
for the early removal of the lens. Sometimes ripening
may be hastened by massage of the lens. Indirect mas-
sage is done by tapping the anterior chamber, drawing
off the aqueous so that the lens falls against the cornea,
and then stroking the cornea with a corneal spatula, within
the area of the pupil previously dilated with cocain. Or
iridectomy may be done, and similar stroking of the cornea
over the area of the pupil and the coloboma in the iris.
Direct massage is done either with or without iridectomy, by
introducing a spatula into the anterior chamber and strok-
ing the anterior capsule of the lens. The author prefers
the operation first mentioned. After it, if the lens has a
firm nucleus, the anterior cortex rapidly becomes ha/y
and within two to six weeks entirely opaque.
Even without any such preliminary operation a cataract
may be removed before maturity. The special difficulties
of such removal are that portions of the cortex, still clear,
remain adherent to the lens-capsule, and later become
opaque, preventing good vision until they have become
absorbed, or are removed by an operation for secondary
cataract ; and that the swollen lens may require a slightly
longer corneal incision. But after fifty years of age the
bulk of the lens can be removed as nucleus ; the cortex
left, if not in the anterior chamber, will cause no irrita-
tion ; and the waiting even for a secondary operation or
the absorption of the remaining cortex is not so irksome
after the principal operation is safely past. In the hands
CRYSTALLINE LENS. 417
of skilful operators the risks of extraction are not mate-
rially increased by immaturity of the cataract.
Mature or complete cataract is to be treated by extrac-
tion. The operations and the preliminary and after treat-
ment are described in Chapter XIX. The writer prefers,
for most cases, extraction without iridectomy, as being a
simpler operation and leaving the patient with slightly
better vision and less dependent on his glasses. But
when the iris is very rigid or is bound down by posterior
synechise, or there is a strong probability of prolapse of
the iris, because the patient is restless and unruly, or the
eyes prominent, extraction with iridectomy is better.
Before doing extraction, care should be taken to have the
patient in the best physical condition that he is capable
of, and to make sure there is no chronic conjunctivitis, or
mucopurulent accumulation in the lacrimal passages that
will be liable to infect the cornea! wound.
Glasses. — After cataract extraction, a secondary opera-
tion may be necessary (see Secondary Cataract), and the
patient is compelled to wear glasses. If the ametropia
has been low before the cataract, removal of the lens will
leave hyperopia of 10 to 12 D. ; and cataract extraction
commonly leaves astigmatism against the rule, which is
at first very high, but ultimately diminishes to less than
3 D. The changes in refraction may continue for some
months, and until they are complete, permanent glasses
cannot be fitted. For near work convex 3 D. spherical
must be added to the distance-glasses. Patients often
complain of the distortion produced by their strong
glasses, to which on account of their age they become but
incompletely accustomed, and only after a long time.
When both eyes are the seat of cataract, the second
should be operated on when its cataract becomes mature.
Both eyes should not be risked by operation at the same
time. But if both cataracts are ripe, and the eye first
operated on does well, the second operation may be done
within a few days.
Prognosis. — Of persons over fifty years of age who
show distinct opacity of the crystalline lens, probably not
27
418 PROGNOSIS OF CATARACT.
more than one in ten ever requires operation. The early
appearance of such opacity, and its rapid and continuous
increase, point toward a probable need of extraction ; yet
such cases may at any time cease to be progressive.
Nuclear opacity is apt to be slowly progressive, the cho-
roidal form rarely reaching complete maturity. Opacities
recently formed, or progressive, are more apt to be in-
definite or hazy. Those that have ceased to change, are
sharply outlined in clear lens-substance. But regarding
the progress of cataract there is always great uncertainty,
and a definite prognosis can never be given.
Cataract extraction brings improved vision in over
90 per cent, of the cases (97 per cent, of the author's
cases of simple extraction) ; but cataract occurs in eyes
not otherwise entirely healthy, so that full vision is only
attained exceptionally, even with the strong convex lenses
they require. The means of excluding cases not likely
to be benefited are given under diagnosis. If light-pro-
jection and quantitative perception are defective, removal
of the cataract, however successful, will not improve
vision, except in a few cases in which the opacity is
extremely dense. The extraction of a hypermature
cataract is liable to be followed by inflammation of the
uveal tract, and a poor visual result.
After cataract extraction, vision generally becomes
impaired through thickening of the capsule, (secondary
cataract), unless the operation for this condition has been
done shortly after the extraction. In about 1 per cent,
of cataract extractions, glaucoma follows, especially after
operations for secondary cataract. Patients that have suf-
fered from cataract are quite as liable as others of their
age to choroidal disease, optic atrophy, and detached
retina.
Juvenile or Soft Cataract. — Cataract occurring in
young persons is usually devoid of a firm nucleus, such
nucleus as existed in the lens having been broken down by
the degenerative process. It presents the appearance of
senile cataract, except that the pupil is apt to appear more
white and uniform in color. A perfectly uniform milky
DISEASES OF THE CRYSTALLINE LENS. 419
appearance indicates a fluid cataract. Soft cataract is com-
monly traceable to a distinct cause. A few cases are con-
genital; some are due to traumatism ; some are probably
due to convulsions, at least the association of soft cataract
with previous general convulsions is common ; diabetes
causes some cases; a few seem due to early senile
changes in the lens.
Treatment. — Soft cataract does not usually require
extraction. If largely fluid, an incision 5 to 8 mm. long
in the cornea, with a similar shorter incision in the ante-
rior capsule, will allow it to be pressed out, or drawn out
through a suction currette. If more consistent, it may
be opened by discission and allowed to undergo absorption,
the process being hastened from time to time by repeat-
ing the needling ; any part remaining unabsorbed may
afterwards be extracted. No fixed age can be set, up to
which needle operations to produce absorption are proper,
and after which extraction must be done ; but generally
before twenty absorption can be relied on, and after thirty
it is rarely sufficient. In doubtful cases we may begin by a
needle operation that makes but a small opening in the
anterior capsule, being prepared to follow it, if necessary
by extraction.
Partial Cataract. — All lens-opacities are at some
time partial ; but in some cases a fixed and characteristic
portion of the lens is involved, and there is no tendency
to extension of the opacity to other parts, for many years,
or throughout life. Such opacities often affect both eyes.
Cataracts of this kind are named by the characteristic
form or situation of the opacity.
Anterior polar cataract (anterior capsular cataract
or pyramidal cataract) occurs at the anterior pole of the
lens, involving the capsule, and is usually somewhat pyra-
midal in shape. It may be congenital, possibly the
remains of pupillary membrane ; or it may be acquired in
early childhood through perforation of the cornea. (See
page 280.) Anterior polar cataract is usually but a small
speck upon or beneath the surface of the lens, which does
420 ANTERIOR POLAR CATARACT.
not sufficiently obstruct the pupil to require treatment.
Its appearance and location are illustrated in Fig. 129.
FIG. 129. — Anterior polar or pyramidal cataract. A, section showing project-
ing opacity on anterior surface of lens. B, pupil by oblique illumination. C,
pupil by ophthalmoscopic illumination.
Posterior polar cataract may be congenital, arising
from incomplete clearing of the point at which, during
fetal life, the hyaloid artery reaches the posterior capsule
of the lens. This form consists of a small rounded
opacity situated to the nasal side of the posterior pole
of the lens, and only discovered with the ophthalmoscope,
with which it appears as a small black dot against the red
fundus-reflex. Another form is a larger mass of opacity,
often of a radiating figure, which developes in connection
with high myopia, choroidal disease, or chronic retinal
disease ; and which may progress to complete cataract.
This form interferes some with vision. It is illustrated
in Fig. 130.
0
FIG. 130.— Posterior polar cataract. A, section showing opacity just within
the posterior capsule. B, appearance of dilated pupil by oblique, and C, by
ophthalmoscopic, illumination.
I/amellar Cataract (Zonular or Perinuclear Cata-
ract}.— In this form there is opacity of a layer surround-
ing the nucleus, the nucleus within and the cortex outside
this layer remaining clear. This distribution of the opacity,
and the appearances it causes are illustrated in Fig. 131.
DISEASES OF THE CRYSTALLINE LENS. 421
In rare cases there are two such complete concentric
zones of opacity, separated by clear lens-substance. More
frequently, the periphery of the lens presents commencing
opacity of a second layer ; such partial opacities are called
" riders." The appearances of lamellar cataract resemble
those of nuclear cataract in that both present a circle of
opacity at the center of the pupil, surrounded by clear
FIG. 131. — Lamellar cataract. A, section of lens. B, pupil dilated seen by
oblique, and C, by ophthalmoscopic, illumination.
lens-substance. But they differ in that in lamellar cataract
the opacity is most dense at the margin of the circle, while
in nuclear cataract it is most dense at the center.
This form of cataract is congenital, or arises in early
childhood. It is often associated with a history of con-
vulsions, dental defects, or other congenital deficiencies
of the eyes.
Fusiform cataract is a spindle-shaped opacity ex-
tending from the anterior to the posterior pole of the lens.
This is also called cor aliform cataract. Specks of opacity
may be found in various parts of the lens remaining
unchanged throughout life. Such a speck at the center of
a nucleus would be called central cataract.
Diagnosis. — Partial cataract is most certainly detected
by careful search with the ophthalmoscope. The exact
location of the opacity is to be determined by the methods
described in Chapter IV (see page 81). A small partial
cataract might be mistaken for a foreign body in the
lens.
Treatment. — Partial cataract is serious in so far as it
obstructs the pupil. Often the complete dilatation of the
pupil produces great improvement of vision. In a few
of these cases an optical iridectomy enabling the patient to
422 PARTIAL CATARACT.
see past the obstruction will be beneficial ; but usually if
the impairment of vision justifies operative interference,
it is best to remove the lens, by extraction in adults, or
discission in children. The loss of accommodation by
removal of the lens is of less importance in these cases,
because .with decided lens-opacity, the accommodation is
usually found greatly diminished. Then, too, a lens with
partial opacity is especially liable to complete cataract at
a later period. Even opacity confined to the capsule, or
lying on the normal capsule, as the exudate in occlusion
of the pupil, cannot be removed without removal of the
whole lens.
Secondary Cataract (Capsular Cataract or After-
cataract}. — The common operations for removal of cata-
ract leave a part «r the whole of the lens-capsule in the
eye. Operations for getting rid of the capsule with the
lens have been devised ; but their difficulty and risk are
not compensated by their advantages. Usually the cap-
sule includes the remains of the cortex adherent to it.
The transparency of the capsule is disturbed by the ex-
traction of the lens, and the adherent cortex at first swells
and becomes opaque ; but after this the capsule clears up
and the cortex is absorbed, and the vision improves to a
maximum a few weeks or months after the extraction.
Then there occurs a slow process of thickening of the
capsule, which causes vision to deteriorate, until, commonly
within two years, it has fallen a good deal below the
maximum attained shortly after operation. In other
cases, as after the extraction of an unripe cataract, the
cortex left behind causes an opacity that entirely obstructs
the pupil, and would require many weeks or months for
its absorption. Or after the extraction of a hypermature
or complicated cataract the capsule is so decidedly opaque
as to seriously impair the vision. Again, after discission
of soft cataract there often remains a comparatively thin,
but tough opaque mass, which tends to persist indefinitely
without further absorption and to become calcareous.
These are all included under the heading of secondary
cataract.
DISEASES OF THE CRYSTALLINE LENS. 423
Diagnosis. — With the ophthalmoscope, if the obstruc-
tion of the pupil is partial, black lines or masses are seen,
which are found to be in the plane of the pupil ; and the
details of the fcmdus are found to be indistinct. The oph-
thalmoscopic appearances of secondary cataract are shown
in Fig. Io2. By oblique illumination these opacities
FIG. 132.— Secondary cataract. Appearance of the pupil by ophthalmoscopic
illumination. Two iritic adhesions. The capsule clearer in upper part of the
pupil.
appear gray or brown. When the obstruction is com-
plete, the pupil is seen to be occupied by a gray or white
mass resembling a mature cataract; but this is distin-
guished from primary or lenticular cataract by the great
depth of the anterior chamber, and tremulousness of the
iris, showing that the bulk of the lens has been removed ;
and by history of the previous cataract operation of some
sort. It is to be distinguished from opacity in the an-
terior vitreous by the general condition of the eyeball.
In simple secondary cataract the tension is usually normal
or not much diminished, and the light-projection and
quantitative perception are good. But vitreous opacity,
such as might simulate secondary cataract, is often at-
tended with decided lowering of the intra-ocular tension,
and the loss of light-projection or perception.
Treatment. — Secondary cataract is to be met by mak-
ing a sufficient opening through it, or by extracting it
from the eye. The former operation is resorted to for
comparatively thin membranes that can be readily cut
or torn through, and which are likely to retract and leave
a clear opening after division. The removal of the
opacity is indicated when it is comparatively thick and
rigid, and especially when it occupies a small area just
behind the contracted pupil. The operations for these
424 SECONDARY CATARACT.
purposes are described in Chapter XIX. They are not
without danger. They may cause infection of the eye, and
general inflammation of the uveal tract.
Dislocation of the lens (luxation of the lens, ectopia
lentis) occurs sometimes as a congenital anomaly. The
lens is displaced usually upward, but sometimes in other
directions. The displacement is commonly symmetrical
in the two eyes, but may be confined to one. The edge
of the lens may be seen in the pupil, appearing with the
ophthalmoscope as a dark line on the red background,
distinguishable from anything else by its even curve. Its
appearance is illustrated in Fig. 133. Vision is commonly
FIG. 133.— Congenital dislocation of the lens upward and to the nasal side in
the left eye. Curved lens-margin seen crossing the dilated pupil.
impaired on account of imperfect focussing, either through
the edge of the lens where the eye is myopic, or outside
the lens where it is hyperopic. Rarely the two sets of
rays cause monocular diplopia. The iris is pushed for-
ward on the side toward the lens. In some cases the lens
seems fixed in its anomalous position, but often it is
movable. In a few cases, the patient has been able to
swing the lenses into position behind the pupil, or allow
them to drop away by changing the position of his head
and eyes.
The discolated lens may remain perfectly clear, although
it generally appears a faint gray by oblique illumination.
If entirely loosened from its normal connections, it gradu-
ally becomes opaque.
Occasionally spontaneous dislocation of the lens occurs
through relaxation or atrophy of its suspensory ligament.
Often it only amounts to a partial dislocation, the lens
falling back at one part, making the depth of the anterior
chamber unequal in different portions and at different
DISEASES OF THE CRYSTALLINE LENS. 425
times. In other cases the dislocation is complete, the lens
falling quite away from the pupil, and lying usually in
the lower part of the vitreous chamber. Such a freely
movable lens is liable to become displaced through the
pupil into the anterior chamber.
When dislocated into the anterior chamber, the clear
lens may be recognized by the curved line of brilliant
reflex from its edge. If opaque, it of course hides the
central portion of the iris, and is distinguished from opa-
city of the cornea by its distinct edge and greater depth
when viewed binocularly. It may be closely simulated
by the exudate in spongy iritis. A dislocated lens if at
all movable is a constant source of danger in the eye. It
is liable to cause disorganization and opacity of the
vitreous, to set up chronic inflammation of the uveal tract,
or to bring on glaucoma.
Treatment. — Except in cases where the lens is firmly
fixed in its abnormal position, and does not interfere with
vision, a dislocated lens should be removed — by discission
and absorption in young eyes, or by extraction in later
life. Sometimes a dislocated lens can be extracted like
an ordinary cataract, sometimes it requires the use of a
lens-spoon, and sometimes a two-pronged fork called a
bident, or a straight needle, has been thrust behind it to
hold it forward to the pupil, in position for extraction.
Sometimes a lens dislocated into the anterior chamber
can be returned behind the iris (where it is less likely to
cause immediate harm) by dilating the pupil fully with
homatropin, and manipulating the eyeball. After it has
thus been returned, it may be kept behind the pupil by
the instillation of eserin (physostigmin) solution once or
twice a day.
In a few cases of traumatic subluxation the lens seems
to be restored to its normal position and support under
long rest of the eye, with the use of mydriatics. Yet
mydriatics must be used cautiously when the lens is dis-
located, on account of the possibility of their increasing
the liability to glaucoma.
Coloboma of the lens is a congenital anomaly in
426 COLOBOMA OF THE LENS.
which the lens appears notched, usually at its lower mar-
gin. It is rare, and mostly associated with coloboma
o
FIG. 154.— Congenital coloboma of the lens seen through coloboma of the iris
downward.
of the iris and choroid, as in the case illustrated in Fig.
134.
I/enticonus is a rare irregular protrusion of one of
the lens-surfaces, usually the posterior, causing irregu-
larity of refraction a little like that of conical cornea.
It may be studied*by skiascopy ; and by shifting the point
of view, the irregular refraction is seen to depend on the
lens rather than the cornea.
Aphakia, or complete absence of the lens, may occur
as a congenital anomaly. But most of the cases supposed
to be of this class are really cases in which a very small
lens is dislocated so as to be invisible.
Injuries of the lens are considered in Chapter XVII.
DISEASES OF THE VITREOUS.
Vitreous Opacities. — Impairment of transparency
is the most constant symptom of disease of the vitreous
body. It is a symptom, too, that is prominent in many
cases of diseases of the choroid, ciliary body and retina,
for it is upon the vessels of these parts that the non-
vascular vitreous depends for its nutritive supply.
Symptoms and Varieties. — Vitreous opacities vary
from the slightest exaggeration of the normal specks that
can be perceived subjectively in the healthy eye (see page
42) to great masses that render the eye practically blind.
Opacities of much importance are to be recognized by
the ophthalmoscope, although some too small to be visible
do cause annoying shadows, especially when the retina is
hyperesthetic from eye-strain.
•DISEASES OF THE VITREOUS. 427
Perfectly diffuse haziness of the vitreous sometimes
occurs in connection with acute hyalitis, rotinitis, cyclitis,
or choroiditis. Visible opacities have the forms of fine
dust, larger flakes, shreds or bands, and large membranous
masses. They are illustrated in Fig. 135. The dust-like
opacity is commonly due to syphilitic chorioretinitis or
FIG. 135.— Opacities of the vitreous, dust-like at lower part of pupil, with
threads and membranous masses above.
cyclitis. The fakes and shreds are formed in chronic
choroidal disease, or progressive myopia ; the large float-
ing membranous masses are usually the remains of hemor-
rhages into the vitreous. Extensive organized mem-
branes fixed in position by firm attachment to the retina
are supposed to have developed as a result of chronic
retinal disease, and are spoken of as retinitis proliferans.
Impairment of vision from retinal opacities varies with
their density and situation. Often the patient can by
certain movements of the eyes or head throw an obstruct-
ing opacity out of the line of vision, and so, for an instant,
see much more clearly. In other cases the vision grows
better when the eyes are for some time kept steady, and
the floating masses allowed to settle down.
Diagnosis. — Subjectively the shadows of vitreous
opacities may be confused with scotomas due to retinal
or choroidal disease, with after-images of bright lights,
or with the photopsias of disturbance of the visual centers.
With the ophthalmoscope the opacities may be mistaken
for pigment-masses in the choroid, or opacities in the lens
or cornea. The characteristic of the vitreous opacities is
428 VITREOUS OPACITIES.
their peculiar tremulous movement and gradual settling
to a position of rest after any movement of the eyes.
Their usual shapes diifer, too, quite decidedly from those
of choroidal pigment-patches or lens-opacities, and their
depth in the eye as measured by their refraction (see page
134) or parallax (see page 82) indicates their character.
Treatment. — This must be chiefly the treatment of the
cause of the opacity, or the disease with which it is asso-
ciated. When no other ocular lesion is discoverable, any
abnormality of the general health should be attended to.
Alteratives, especially mercuric chlorid and potassium
ioclid, in moderate doses long continued, may be quite
beneficial. Pilocarpin sweats, abstraction of blood from
the temple, and local applications of moderate galvanic
or high frequencyacurrents have been reported beneficial.
Large membranous opacities that are chronic may be
divided with a narrow knife, causing improved vision and
shrinkage of the opacity. In all cases, choroidal disease
is probably present and requires treatment. Nasal dis-
ease is also a probable cause of vitreous opacities.
Prognosis. — The smallest vitreous opacities, those that
cause the muscce volitantes are apt to occasion the greatest
alarm. Generally the patient may be assured that they
are not a sign of danger. But the prognosis as to restora-
tion of the transparency of the vitreous is at best doubtful.
Syphilitic opacities and those following hemorrhages
sometimes clear up remarkably, even after many months ;
those attending chronic choroidal disease and high myopia
generally remain, although they may become less annoy-
ing.
Fluid Vitreous (ftynchisis). — Undue fluidity of the
vitreous is only recognized by the unduly free movement
of opacities in it. It very generally occurs with exten-
sive vitreous opacities. It is of practical importance by
indicating degenerative changes in the eye, and by com-
plicating operations for cataract or glaucoma.
Sparkling synchisis (synchisis' scintillans) is the name
given when there are scattered through the fluid vitreous
small crystals of cholesterin, tyrosin and phosphates,
DISEASES OF THE VITREOUS. 429
which are seen with the ophthalmoscope to glitter and
flash as they move, after any movement of the eye. This
condition is usually found in degenerated eyes, but is not
incompatible with perfect vision. It is not affected by
treatment.
Hyalitis. — Inflammation of the vitreous arises from
inflammation of the retina, ciliary body or choroid, or
by infection through a penetrating wound, or foreign
body. It is marked by diffuse opacity, the accumulation
of pus-cells in various portions, and the symptoms of the
disease with which it is associated. It tends to run a
chronic course. A few cases partly clear up ; but usually
the vitreous comes to present the yellowish mass, called
pseudo-glioma (see page 343), sight being lost and the ten-
sion of the globe permanently diminished. Eare cases of
traumatic hyalitis make complete recoveries.
Treatment. — Hyalitis is to be regarded as rather a
symptom of the disease causing it, to which the treatment
is to be directed. It is good surgery to remove a sight-
less eye containing a collection of pus in the vitreous,
even though there be no chance that it conceals a foreign
body, or question of its being glioma cif the retina.
Hemorrhage into the vitreous comes from the
uveal tract or retina, and is due to traumatism, vascular
disease, or possibly alteration in the blood itself. Cases
of obscure etiology occur in early adult life. It causes
dark masses, which may appear red on the margins.
Vision may be reduced by it to bare light-perception, or
objects seen through it may appear red. The clot is
slowly absorbed, and there may be restoration of good
vision, but generally some opacity remains.
Treatment. — At the time of the hemorrhage, rest,
with the head high, cold to the eye, the taking of blood
from the temple, and cardiac depressants, may be em-
ployed. Subsequently careful attention to the general
health, with pilocarpin sweats, and small doses of potas-
sium iodid, may be resorted to. Remaining membranous
opacities may be cut through after they become non-
430
HEMORRHAGE INTO Till'. VITRKOUS.
vascular, and all tendency to inflammation or recurrence
of hemorrhage appears to have passed away.
Blood-vessels in the vitreous are sometimes formed
after the occurrence of repeated hemorrhages. They
arise from the retinal vessels, pass forward into the vitre-
ous in the form of net-work of small vascular loops,
more or less enveloped in opacity, and after a few months
or longer may shrink and entirely disappear. A mass of
such vessels is illustrated in Fig. 136.
FIG. 136.— New-formed vessels in the vitreous, hiding part of the upper tem-
poral vessels in the left eye. These vessels, being in advance of the fundus,
could, not be seen distinctly at the same time as the fundus, as represented in
the picture.
Detachment of the vitreous alone is not clinically
recognized ; but it attends detachment of the retina, and
shrinking of the exudate after cyclitis.
Parasites in the Vitreous. — Filaria, hydatids, and
cysticercus have been found in this situation. In North
Germany cysticercus is not very rare. It appears while
alive as a round bluish-white cyst ; from which extends
DISEASES OF THE VITREOUS. 431
the white neck, with the head moving slowly back and
forth independent of the movements of the eye. After
its death it may become so covered with lymph as to
be unrecognizable with the ophthalmoscope. If the para-
site is not removed, the eye is liable to become blind and
shrunken.
Persistent Hyaloid Artery. — In early fetal life a
branch from one of the retinal arteries passes forward
from the optic disk to the posterior pole of the lens,
where it breaks up into many minute branches. This
vessel is called the hyaloid artery. Usually it atrophies
before birth, but in a few cases, some traces of it remain
throughout life, and in a very few it continues to carry
blood. The most common trace of it is a speck on the
posterior capsule of the lens ; next in frequency are tags
of gray tissue on the optic disk, and sometimes a wavy,
gray connective-tissue chord marks its course through the
vitreous.
B c
FIG. 136 a. —A, B, C, persistent hyaloid remains.
The more common types of peristent remains of the
hyaloid artery, as they appear in the fundus, are shown in
the accompanying Figures, A, B, C. (A] represents the
membranous form, partially concealing the vessels on the
disk. In the case represented, it had a definite outline.
Often it shows a number of irregular tags, or a gradual
432 PERSISTENT HYALOID ARTERY.
transition into normal vitreous tissue. (J>) shows a
cyst-like formation upon, or attached to one of the
vessels of the optic disk. The nature of such bodies
may seem puzzling, but they are congenital, and prob-
ably associated with retrograde changes in the hyaloid
vessels. (0) shows the rarer form which more closely
resembles a vessel, and in which may be minute vessels
carrying blood.
Persistent hyaloid remains must be distinguished from
products of intra-ocular inflammation, as the exudate of
retinitis near the macula, vitreous opacities of inflamma-
tory origin, or proliferating retinitis (see page 371).
They may also be mistaken for foreign bodies in the vit-
reous, or for intra-ocular cysticercus.
CHAPTER XV.
DISORDERS OF TENSION OF THE EYEBALL.
Normal Intra-ocular Currents and Pressure.—
The preservation of the shape of the eyeball, the curva-
ture of the cornea, and the normal relation of the dioptric
surfaces to the retina depend on the intra-ocular tension.
The sclerocorneal coat is a closed sac fitted to resist in-
ternal pressure. Its contents, pressing outward at every
point, keep it distended, against the external pressure of
the lids, extra-ocular muscles, and orbital tissues. This
normal intra-ocular tension equals the pressure of a
column of mercury 25 to 30 mm. (1-1.2 inches) in
height. It varies somewhat within the limits of health,
and may vary in disease from nothing to the equivalent
of 200 mm. (8 inches) of mercury or more.
The cornea, crystalline, and vitreous humor are non-
DISORDERS OF OCULAR TENSION. 433
vascular, and are nourished by fluid from the capillaries
of other tissues. The supply of this fluid must be kept
up continuously, or the nutrition of these parts of the eye
would suffer. This fluid, constantly poured into the eye,
must as constantly escape from it, or undue distention of
the eyeball and increased intra-ocular tension result. In-
creased inflow must be balanced by a free passage through
the channels of escape. This suggests the existence of a
mechanism co-ordinating inflow and outflow. But of the
portion of the nervous system for the regulation of intra-
ocular tension we know little.
The inflow of fluid comes through the cornea from the
vessels of the pericorneal zone, from the choroid, and
particularly from the vessels of the ciliary processes.
From the latter sources the fluid passes through the
vitreous body around the crystalline lens, forward through
the pupil. The principal escape of fluid from the eye
occurs at the angle of the anterior chamber, where the
cornea is devoid of epithelium, and large lymph-spaces
connect the anterior chamber with the canal of Schlemm,
FIG. 137.— Path of intra-ocular fluids.
a large drainage-channel within the sclera. The path of
the intra-ocular fluid is illustrated in Fig. 137.
Diminished intra-ocular tension may arise from dimin-
ished inflow or increased outflow ; or increased tension
from increased inflow or diminished outflow. Of these
possible conditions most is known about diminished inflow,
causing lowered tension; and diminished outflow, causing
increased tension.
28
434 INTRA-OCULAR TENSION.
Intra-ocular tension is tested by placing the tips
of two fingers, usually the two fore-fingers, either on the
upper lid above the cartilage when the lids are lightly
closed and the eye rolled down, or upon the sclera below
the cornea when the eye is rolled up. Making pressure
with one finger while the other steadies the eyeball, the
amount of pressure required to dimple or press in the sur-
face of the eye is a measure of the intra-ocular tension.
Care must be observed that a rigid sclera is not mis-
taken for increased tension. The best guide as to change
of tension is comparison of the resistance of the eye
under examination with that of a normal eye, — either the
patient's other eye if normal, the surgeon's eye, or that of
some third person. Allowance must be made for individual
peculiarities and increasing - rigidity of the sclera with
increasing age.
By this method very exact knowledge of the changes
of intra-ocular tension cannot be attained, and the common
plan of indicating such changes is probably as exact as
could be practically useful. This plan, suggested by
Bowman, is :
Normal tension, T n
Slight, but distinct, increase of tension, + T 1
Very marked increase of tension, . + T 2
Greatest increase of tension, + T 3
Slight, but distinct, decrease of tension, — T 1
Very marked decrease of tension, — T 2
Eyeball perfectly soft and unresisting, — T 3
Sometimes +T? and — T? are used to indicate a
doubtful increase or decrease.
GLAUCOMA.
Glaucoma is increased intra-ocular tension, with the
causes and results of such increase. The word originally,
in the ancient Greek, referred only to the reflex of light
in the pupil, including, among other conditions, cata-
ract. But as other conditions have been classed under
other titles it has gradually come to include only the
DISORDERS OF OCULAR TENSION. 435
cli. souse causing blindness with increased tension of the
eyeball.
Primary glaucoma includes all cases of increased
intra-ocular tension not preceded by injury or other
marked disease of the eyeball. It includes glaucoma
with exacerbations, and simple glaucoma. Secondary
glaucoma includes several forms of diverse origin, but
with the common tendency to blindness with high
tension.
Glaucoma with exacerbations (inflammatory glau-
coma, acute and chronic) is marked by a sudden appear-
ance or sudden increase of its symptoms, which subse-
quently remit or intermit, but again recur. The recurring
exacerbations gradually become more severe, each time
leaving the eye damaged to a greater extent, and finally
they end in complete blindness, with great pain.
Symptoms and Course. — Early loss of the power of
accommodation, increasing hyperopia and the appearance
or increase of astigmatism against the rule, are thought
to indicate the probability of glaucoma (incipient glau-
coma). Frequent changes in the amount or direction of
the astigmatism, or inability to use the eyes to a normal
extent without obvious reason for it, have the same sig-
nificance. But these symptoms cannot be regarded as
surely symptoms of glaucoma, since they all occur in
eyes that never show any tendency to increased tension.
The first positive symptom to attract attention is
usually disturbance of vision. The vision in one or both
eyes is temporarily blurred, or a ring or halo is noticed
around the lamp-flame at night. This halo is 10 degrees
or 12 degrees in diameter and exhibits the colors of the
rainbow, with the violet inward, the red outward. Like
the dimness of vision, it is at first entirely intermittent,
is seen when the patient is tired or indisposed, and after
a good night's rest, disappears. At the periods of im-
paired vision, the pupil is somewhat dilated, although at
other times still of normal size. Close examination will
show that the anterior chamber is shallow, especially
toward its periphery.
436 GLAUCOMA WITH EXACERBATIONS.
The obscurations of vision recur, become greater, last
longer, are attended with more marked dilatation of the
pupil, and subsequently with pain. They also become
marked by redness of the pericorneal zone, and distinct
attacks of acute inflammation, attended with general
cloudiness of the cornea, and consequent alteration of the
appearance of the iris, and blurring of the ophthalmo-
scopic image. Examination will now show that the field
of vision is becoming impaired, and probably the acute-
ness of vision at the fovea will remain below normal
between the attacks. With the progressive impairment
of central vision and the narrowing of the visual field the
halo symptom becomes less noticeable or disappears
altogether.
If the case b^not efficiently treated, the exacerbations
become more frequent and severe, the remissions less
complete. The permanent alteration of the field and of
central vision become greater, until blindness, constant
pain and continuous inflammation are established (abso-
lute glaucoma). After a variable period of pain and in-
flammation these may subside, leaving a sightless but
painless eyeball ; or the intra-ocular tension may cause
staphyloma and rupture, with partial escape of the con-
tents of the globe, succeeded sometimes by panophthal-
mitis.
If not checked by treatment, the course of the disease
is always to complete and irremediable blindness. In
rare cases this results from the first outbreak noticed, or
through one violent outbreak preceded by only a few
insignificant exacerbations (glaucoma fulminans). In rare
cases, after one or two exacerbations, the eye remains free
from them for some time, or the excerbations occur at
long intervals and increase but little in severity.
Corneal Anesthesia. — At first, during the exacerbations,
and later continuously, the cornea becomes comparatively
insensitive to touch ; and we have an exquisitively pain-
ful eye showing less reaction when lightly touched on the
cornea than the normal fellow eye.
DISORDP1RS OF OCULAR TENSION. 437
Pain always attends glaucoma with exacerbations, and
usually in the later stages is extremely severe. The
writer has known a patient to lose fifty pounds weight in
six weeks, through the suffering from glaucoma. The
pain is not relieved by drugs or by any form of local
treatment, except such as diminishes the intra-ocular
tension.
The impairment of the field of vision begins commonly
in the periphery, is usually greater on the nasal side, and
is apt to be permanent. Fig. 138 shows a common form
FIG. 138.— Field of vision in glaucoma.
of limitation ; but the form may vary greatly. In some
cases the outline of the field becomes very irregular, often
scotomas may be found. Central vision is sometimes lost
while some eccentric vision is still retained, but ultimately
all perception of light is lost.
The ophthalmoscopic symptoms include the appearances
produced by pressure. The most striking is cupping of
the optic nerve (see Plate II, 6, and Fig. 3£, p. 97). The
increased tension also causes collapse of the arteries in the
interval between the pulse-waves, giving rise to arterial
pulsation. This may be seen either at the margin of the
cup, or where the vessels appear on its floor. Pulsation
of the veins in this situation is normal in many eyes.
Arterial pulsation is one of the first symptoms of increased
intra-ocular tension. But it is often difficult to detect,
and may be temporarily abolished by previous pressure
438
SYMPTOMS OF GLAUCOMA.
on the eyeball, as in testing intra-ocular tension. The
formation of a glaucoma-cup requires time. During the
early exacerbations, no sign of it will be detected. AY hen
formed, however, it is permanent, and is usually the most
positive sign of glaucoma to be found between the exacer-
bations. In chronic glaucoma the optic disk is usually
surrounded by a comparatively uniform ring or halo of
FIG. 139.— Fundus in chronic glaucoma. Disk deeply cupped to its extreme
margin, and surrounded by a white ring or " halo " of cnoroidal atrophy.
Vessels disappear on sides of the glaucoma-cup.
choroidal atrophy. The ophthalmoscopic symptoms of
glaucoma are illustrated in Fig. 139.
Causes and Pathology. — On the average, out of ten
cases of glaucoma six occur in women and four in men.
Jews are particularly liable to it. Negroes suffer from it
but rarely. The liability is hereditary in certain families ;
and it increases with age up to seventy, and after that
declines. It is rare before the age of forty. Still, sev-
DISORDERS OF OCULAR TENSION. 439
eral cases have been reported occurring before the age of
twenty. An exacerbation may be excited by grief, mental
shock, worry, exhaustion, and especially by dilatation of
the pupil with a mydriatic.
Examination of eyes removed for absolute glaucoma,
the clinical history of the disease, and the influences of
treatment, all indicate that a very important factor in
causing increased tension in the eyeball, is blocking of
the outflow from the anterior chamber. Eyes blind with
this disease show the periphery of the iris permanently
adherent to the posterior surface of the cornea, the lymph-
channels being entirely closed. This condition is illus-
trated in Fig. 141, in contrast with the normal condition
FIG. 140. FIG. 141.
Angle of the anterior chamber : Fig. 140, in the normal eye ; Fig. 141, in a
glaucomatous eye.
shown in Fig. 140. The action of mydriatics also illus-
trates the influence of blocking the angle of the anterior
chamber. The dilatation of the pupil causes thickening
of the periphery of the iris, thus closing for the time the
outflow channels. Cocain, while dilating the pupil, so
contracts the blood-vessels as to prevent thickening of the
iris periphery ; and it does not show the same tendency
to produce an outbreak.
The conditions which bring about secondary glaucoma
also act the same way. Dislocation or swelling of the
lens pushes the periphery of the iris forward. Occlusion
of the pupil, causing iris bombe, does the same thing.
Eserin (physostigmin) by contracting the pupil, thins the
periphery of the iris and draws it away from the cornea,
thus reopening the outflow channels.
Priestley Smith has shown that the predisposing influence
440 PATHOLOGY OF GLAUCOMA.
of age is also thus explained : The crystalline lens, like
other epithelial structures, continues to grow throughout
life, at least until sixty or seventy years of age, when it
may begin to degenerate and shrink ; the enlarged lens
pressing on the ciliary processes, and through them pushing
forward the periphery of the iris, predisposes to the
blocking of the angle of the anterior chamber. He also
points out that eyes having a comparatively small cornea,
and therefore less space between the lens and the ciliary
processes are more liable to glaucoma. Glaucoma may
be associated with rheumatism, gout, vascular disease, and
disturbances of circulation. Eye-strain has been regarded
as a factor.
Diagnosis. — Glaucoma is characterized by increased
intra-ocular tension ; but a slight increase cannot be recog-
nized with certainty ; and even in glaucoma of long stand-
ing, the tension may much of the time be normal. The
history of repeated attacks or relapses is very suggestive,
and cupping of the disk, with impairment of the field of
vision is quite characteristic. Dilatation of the pupil,
shallowness of the anterior chamber, and dilatation of the
scleral veins, are also important symptoms.
When the premonitory symptoms of glaucoma are
present, but a positive diagnosis cannot be made, the in-
stillation of homatropin or euphthalmin will probably cause
arterial pulsation and other signs of increased tension, if
glaucoma is really imminent. This is a proper diagnostic
procedure, provided its character is explained to the pa-
tient, and his assent obtained to the prompt treatment of
the disease, if thus rendered manifest.
Glaucomatous attacks are sometimes mistaken for
neuralgia, the severe pain being referred to the brow and
cheek rather than to the eye. Such an error can always
be avoided by examining the tension of the eye, the field
of vision, the size of the pupil, and the appearance of the
optic disk.
The haziness of the cornea with pericorneal redness
may cause it to be confused with keratitis ; but with these
symptoms the tension is always raised, and the pupil
DISORDERS OF OCULAR TENSION. 441
somewhat dilated in glaucoma, while in keratitis the ten-
sion would be normal and the pupil rather contracted.
Sometimes glaucoma has been mistaken for erysipelas. It
lacks the tense red skin ; and erysipelas does not present
the changes of the eyeball that mark glaucoma. It
should be remembered that acute glaucoma sometimes
follows or complicates facial erysipelas.
Iritis resembles an exacerbation of glaucoma in pain,
photophobia, impaired vision, and pericorneal redness ;
but in iritis the pupil is contracted instead of dilated,
and often bound down by posterior synechise. Cyclitis
still more closely resembles glaucoma, for, in cyclitis, the
pupil may be widely dilated by a mydriatic, and slight
increase of tension may occur. The existence of deposits
on the posterior surface of the cornea, or the age and his-
tory of the patient, or the integrity of the field of vision,
may decide the diagnosis. In doubtful cases it will be
better to avoid a mydriatic until observation of the case
has settled the diagnosis. The inflammatory exacerba-
tions of glaucoma are generally accompanied by markedly
high tension. Other points as to the diagnosis are con-
sidered with simple glaucoma.
Treatment. — The chief remedy for glaucoma is a large
iridectomy (see Chapter XIX). This is curative in the
sense that in most cases of glaucoma with exacerbations
the increase of tension is permanently relieved, and
further pain and inflammatory attacks prevented. But
the ere is not restored to its original condition ; hence,
the earlier the iridectomy is done, the better the result.
Sclerotomy (Chapter XIX) and radial incision of the
ciliary body are also done to relieve glaucoma. They
should not be depended upon for eyes in which there is a
reasonable chance of saving useful vision by iridectomy.
Stretching the nasal branch of the ophthalmic division of
the fifth nerve has been practised on theoretical grounds,
but is of doubtful value. Jonnesco and Abadie have
recently urged and practiced excision of the cervical sympa-
thetic. In operating on one eye, it is generally well to
instil a myotic in the other, since the excitement and
442 TREATMENT OF GLAUCOMA.
shock of operation sometimes provoke an outbreak in the
second eye.
In commencing or suspected glaucoma the careful cor-
rection of errors of refraction may be beneficial. After
iridectomy there usually remains an increased astigmatism
against the rule, which must be corrected to give the best
vision.
In the earlier stages, while the pupil can still be con-
tracted by them, the instillation of the myotics, eserin,
(physostigmin,) and pilocarpin have a marked influence
in relieving and preventing exacerbations. This influence
is enhanced by combination with cocain, which tends to
lower the intra-ocular tension as well as contract the iris.
In a few cases the use of these drugs has been followed
by no return of increased tension. But they should be
regarded only as palliative. In most cases the myotic
when used for a time gradually loses its beneficial in-
fluence until it becomes quite powerless; and meanwhile
great and irremediable damage may be done to the eye.
Mydriatics (except as indicated on page 440) are to be
carefully avoided in primary glaucoma.
Care should be taken to avoid indigestion, worry, over-
work, loss of sleep, and congestion of the head from stoop-
ing, which may precipitate an attack. The use of natural
mineral waters and other means of increasing elimination
are beneficial. Sometimes an attack can be relieved by a
hot bath, morphin internally, slec'p, or a moderate cathar-
sis. Gentle massage of the eyeball through the closed
lids tends to reduce the tension. When sight is gone and
pain continues, enucleation of the eye is the only thing
certain to give relief.
Prognosis. — Glaucoma left to itself causes blindness,
and usually great pain ; and when well-marked exacerba-
tions have occurred, there is little prospect of farther use-
fulness of the eye except through operative treatment.
In a few cases moderate attacks of glaucoma occur at
intervals for several years before much permanent impair-
ment of vision or other damage results.
Early iridectomy, while the pupil is still mobile, the
DISORDERS OF OCULAR TENSION. 443
fields of vision not much contracted, and the cupping of
the disk slight, commonly cures glaucoma, preserves what
sight remains, and may restore what has been lost within
a few days. In a few cases the repetition of iridectomy
cures when the first operation has failed to do so. Iri-
dectomy done late in the disease is less sure to check it.
When the field of vision is encroached upon to near the
point of fixation, iridectomy may be followed by loss of
central vision. Or the operation may cause temporary
blindness by blood left in the anterior chamber, or hemor-
rhage from the choroid. In a few cases, operation is fol-
lowed in a few hours or clays by a violent return of high
tension, great pain and inflammation, (malignant glaucoma),
for which the eye has to be enucleated. Glaucoma usu-
ally attacks both eyes, but occasionally the second eye
altogether escapes.
Simple glaucoma (chronic primary glaucoma) is a
disease in many respects essentially distinct from glau-
coma with exacerbations. The increase of tension is at
first slight, and very gradual. The anterior chamber is
not especially shallow, the pupil is not dilated, there are
no inflammatory exacerbations. The field of vision may
be greatly contracted before central vision is notably im-
paired. There is no clouding, and no marked anesthesia
of the cornea until late in the disease.
Causes and Pathology. — These are probably essen-
tially different from those of other forms of glaucoma.
There is little evidence of obstruction of the angle of the
anterior chamber, although there may be closure of the
lymph-channels that connect it with the canal of Schlemm,
by connective-tissue hyperplasia. In some cases, high
tension cannot be demonstrated until after the disk has be-
come deeply cupped, or the eye quite blind. In a few cases,
otherwise like glaucoma, no positive increase of tension
can be detected at any time. Yet these cases differ from
simple optic atrophy in having a distinct glaucoma-cup.
It is this form of glaucoma that is probably most closely
connected with gout, rheumatism, general angiosclerosis,
and chronic nerve-exhaustion.
444 SIMPLE GLAUCOMA,
Diagnosis. — The patient is over fifty years of age, and
both eyes are usually affected, though often one consider-
ably earlier or more than the other. The glaucoma-cup
and narrowing of the field of vision are always present,
and tensioji is usually increased. Upon these symptoms
and the absence of others the diagnosis must rest. This
is the form of glaucoma most likely to be mistaken for
cataract.
Prognosis and Treatment. — Simple glaucoma runs a
chronic course, usually lasting several years before blind-
ness is complete ; and often it is not attended by severe
pain. It is also less curable by iridectomy than glau-
coma with exacerbations, and sometimes does badly after
that operation. One cannot, therefore, urge it as in other
forms of glaucoma,. Still, iridectomy done early offers
the best prospect of permanent arrest of the process.
If the patient declines to have an iridectomy done, the
regular instillation of eserin (physostigmin) seems, some-
times, to delay the loss of vision. The internal use of
alteratives and strychnin may be of benefit. Excision
of the superior ganglia of the cervical sympathetic is a
justifiable but uncertain experiment.
Secondary glaucoma includes all cases in which
increased intra-ocular tension arises in consequence of
other serious lesions of the eye.
Hemorrhagic Glaucoma. — In a few cases, after
numerous retinal hemorrhages, glaucoma supervenes.
Often several months elapse between the appearance of
the first hemorrhage and the rise of intra-ocular tension.
After the glaucoma sets in, the course and symptoms are
essentially those of an acute glaucoma with exacerbations.
The prognosis is very bad. Vision is impaired to start
with. Iridectomy usually fails to check the course of the
disease, and eserin is commonly ineffective. A large pro-
portion of cases are only relieved of pain by enucleation.
The second eye mostly escapes, but often the patient dies
in a few years of cerebral hemorrhage or other vascular
disease. Still, iridectomy may save the eye, and, if the
patient so desires, should be tried as a forlorn hope.
DISORDERS OF OCULAR TENSION. 445
Post-iritic Glaucoma. — The effect of annular synechia,
exclusion of the pupil, in damming -back the fluid which
should normally pass forward through the pupil, causing
ballooning of the iris, and thus, obstruction of the anterior
chamber, has already been explained (page 328). In other
oases, iritic inflammation seems to extend to the angle of
the anterior chamber, and by cicatricial contraction to
cause its closure. Eyes that have suffered from chronic
syphilitic inflammation of the uveal tract are liable thus
to devolop glaucoma.
For exclusion of the pupil, a moderate iridectomy done
early and so situated as to give the best optical effect,
may prevent further mischief. For cases in which glau-
coma follows iritis without exclusion of the pupil, the
regular glaucoma iridectomy should be done, great care
being taken to remove a large part of the ciliary border
of the iris. In post-iritic glaucoma, mydriatics may
sometimes be used without danger, and with advantage.
When the iris is extensively bound to the lens-capsule by
adhesions, there is little danger of mydriatics' doing serious
harm in the glaucomatous eye.
Glaucoma with Intra-ocular Growths. — Sarcoma of
the choroid and glioma of the retina, at a certain stage of
their growth, cause increased tension with the general
symptoms of acute glaucoma with exacerbations. The
pain and obvious inflammation of this stage, with loss of
sight, which rapidly becomes complete, and the prospect
of no other relief, often induce the patient to submit to
the only efficient treatment, the removal of the eye.
Glaucoma Following' Traumatism. — Injuries caus-
ing dislocation or much swelling of the crystalline lens
are generally followed by glaucoma ; even where no dis-
turbance of the lens has been noticed, glaucoma has
sometimes followed. Dislocation of the lens into the
anterior chamber is usually followed by a prompt rise of
intra-ocular pressure. Swelling of the lens, always ac-
companied by opacity, or complete luxation, or decided
loosening of the lens from its normal attachments, should
be met by its prompt removal. Slighter displacements
446
SECONDARY GLAUCOMA.
may be treated by rest with instillation of physostigmin, or
a mydriatic, or by a glaucoma iridectomy.
Glaucoma from adherent leukoma arises when the
leukoma tends to extend and to- drag the iris into closer
contact with the cornea, and become a staphyloma. The
tension does not usually get very high, because the staphy-
loma yields before it. The treatment is that given for
anterior staphyloma.
Buphthalmos (hydrophihalmos, glaucoma of childhood)
depends on a congenital failure of the angle of the an-
terior chamber to open as it does in the course of normal
development. This causes increased tension, which, in
the developing eye, leads to gradual distention of all its
coats. The appearance thus caused is illustrated in Fig.
142. The globe Appears large and prominent, the cornea
FIG. 142.— Buphthalmos. (From a patient of Dr. Walter B. Johnson.)
enlarged (keratoglobus, see page 310), and the sclera bluish
on account of its thinning. The lens remains small and
becomes loosely attached. The optic disk becomes deeply
cupped and sight gradually deteriorates. The refraction
is usually myopic, although great flattening of the cornea,
and lack of development of the lens may make it em-
metropic or even hyperppic. A few cases of myopia,
DISORDERS OF OCULAR TENSION. 447
starting in early childhood, and continuing slowly pro-
gressive, but without the above changes in the anterior
segment of the eyeball, are probably of similar character.
Iridectomy or sclerotomy offers some chance of checking
the disease.
DIMINISHED TENSION OF THE EYEBALL.
A perforating wound of the eyeball allowing the free
escape of the aqueous, or of the fluid of the vitreous
humor, at once brings the infra-ocular tension down to
zero where it remains until the wound has become suffi-
ciently closed to prevent further outflow. Then, with the
process of healing, the intra-ocular pressure slowly rises
with the resisting power of the scar until it reaches nor-
mal. Corneal fistula will continue the low tension in-
definitely ; and cystoid cicatrix, due to inclusion of the
iris in the corneal or scleral wound and its imperfect
closure, with drainage of intra-ocular fluid beneath the
conjunctiva, may also keep down the tension. A marked
fall of tension may be produced in the normal eye by
external pressure, as from a tight bandage.
Some cases of injury to the eye or neighboring parts
present prolonged reduction of intra-ocular tension ; some-
times lasting for weeks, without any abnormal opening
for the escape of fluid. This may be due to a nervous
mechanism for regulating intra-ocular tension, set in
action by injury or disease within the eye. Iridocyclitis
is apt to be attended with lowered tension of the globe ;
and when the disease terminates unfavorably the soften-
ing is permanent. Cocain causes a marked decrease of
intra-ocular tension, possibly by mere contraction of
intra-ocular blood-vessels, possibly by influence on a
regulating mechanism. Lowered tension is usually an
unfavorable sign, yet there may be restoration to normal ;
and even the prolonged low tension does not render im-
possible the restoration of useful vision.
Ophthaltnomalacia is a rare condition, characterized
by pain, deep injection, photophobia, and diminished ten-
448 DISORDERS OF OCULAR TENSION.
sion of the eye, coming on without known cause, and
after several hours or days ending in recovery. Such an
attack may recur. It should be met by rest and protec-
tion of the eyes, the use of a weak solution of physostig-
min, and for severe pain, hot applications. Tonics, and
attention to general hygiene are indicated.
CHAPTER XVI.
DISEASES OF THE LIDS, LACRIMAL APPARATUS,
OKBIT, AND ORBITAL WALLS.
Anomalies of the I/ids. — Oryptophthcdmoa is the
name given to mat rare condition in which the imper-
fectly developed eyeball is covered by ordinary skin, the
special structures of the lids and the conjunctiva being
absent. Ablepharia is a partial or total absence of the
lids which leaves the rudimentary eyeball and conjunc-
tival sac exposed. Coloboma of the lid (cleft lid) is a tri-
angular defect, commonly of the upper lid, which is sug-
gestive of hare-lip. It may be associated with dermoids
of the limbus, or small bits of separate cartilage, epitarsux;
or through it the skin may be a continuous covering of the
eyeball. Other deformities, such as symblepharon or
distichiasis, may be congenital.
INFLAMMATION OF THE LIDS.
Blepharitis is a term applicable to any inflammation
of the lid. Most of these are considered under diseases
of the conjunctiva, of the skin, of the lashes, etc. Here
are given a few not readily classified.
Blastomycosis is a chronic purulent inflammation
due to a fungus, the spores of which gain entrance to the
tissues through injury. The surface involved is covered
with crusts, under which are minute abscesses, from which
a sero-purulent discharge may be squeezed out. It
gradually extends by a soft elevated edge. It causes
great deformity of the lids. The treatment includes use
DISEASES OF THE LIDS. 449
of the X-ray locally, and the internal administration of
potassium iodid in large doses.
Marginal Blepharitis (Blepharo-adenitis, Blepharitis
Ciliaris, Ophthalmia Tarsi, Tinea Tarsi, etc.). — Redness
of the lid-margins, with swelling, involvement of the
sebaceous glands with excessive secretion, scaliness of
the lid-margins, sometimes with crusts covering excoria-
tions or distinct ulcers, and disease of the hair-follicles
with alteration of the lashes, is a common clinical picture.
The condition is essentially chronic. Sometimes there is
only recurring redness and swelling with slight scaliness,
more often the condition is constantly present, growing
from time to time better, and again worse. It may last
for years, causing entire loss of the lashes, and permanent
thickening and rounding of the lid-border, with slight
e version and inflammation of the exposed conjunctiva
(lippitudo.)
The disease begins in childhood, usually in the scro-
fulous and poorly cared for. It is closely associated with
a slight chronic conjunct! val irritation or inflammation,
and may depend on nasal disease. Eye-strain is a com-
mon cause. The condition gets worse from use of the
eyes, or exposure to wind or dust.
Treatment. — Errors of refraction should be carefully
corrected. Conjunctivitis, or lacrimal or nasal disease
must have appropriate treatment ; and the general health
and hygienic surroundings must be looked after. Locally
the scabs and the scales should be softened by prolonged
soaking in weak soap-suds, or solution of sodium bicar-
bonate, and thoroughly removed. All lashes that are
loose or which show inflamed follicles should be removed.
Excoriations and ulcers may be touched with silver nitrate
either the solid stick or a 10 per cent, solution. A weak
ointment of yellow oxid of mercury should be well
rubbed into the lid-margin, or an ointment containing
milk of sulphur, or resorcin, may be used ; or the scaly
lid-margin may be rubbed daily with a cotton swab
dipped in 1 per cent, solution of formaldehyd. The latter
will cause intense irritation if it comes in contact with the
29
450 MARGINAL BLEPHARITIS.
conjunctiva. The cleansing and anointing of the lid-
margins should be repeated at bed-time, and the treat-
ment of the conjunctivitis kept tip, often for many weeks.
Stye (hordeoluni) is a small furuncle situated near the
lid-margin, and often pointing around one of the lashes.
It begins with a small red and painful swelling at the
edge of the lid, and goes on to suppuration in about three
to six days. At its height it sometimes causes a general
swelling of the lids that may partly conceal the original
lesion ; but which quickly disappears when the stye opens.
Two or more styes may occur at the same time, and there
is very apt to be a succession of them. They are caused
by a predisposing condition of general health, with eye-
strain, and local infection of glands or hair-follicles from
conjunctivitis, exposure to dust, etc.
Treatment. — The individual stye may sometimes be
aborted by local applications of cold. Generally its
course is hastened and rendered more favorable by bath-
ing with very hot water. It should be opened when sup-
puration has occurred by an incision made with a cataract-
knife parallel to the lid-margin. To prevent farther
recurrences, eye-strain should be removed by proper
glasses and regulation of eye-work. Conjunctivitis or
other local disease should be properly treated. Internally
a laxative should be given with tonics, especially iron.
Potassium bitartrate taken internally seems to deserve its
popular reputation as a preventive of styes.
Abscess may occur in any part of the lids. It is
commonly due to injury or orbital disease. It should be
opened early, and the cavity cleansed with hydrogen
dioxid.
Tarsitis, inflammation of the cartilage of the lid, is
usually due to .syphilis and yields to antisyphilitic treat-
ment. It is marked by thickening and tenderness of the
cartilage over which the skin moves freely. It may also
be associated with marginal blepharatis, or with trachoma,
when the treatment appropriate for those affections is
indicated.
DISEASES OF TlfK LIDS, 451
DISEASES OF THE SKIN OF THE LIDS.
The skin of the lids is subject to most of the skin dis-
eases, as erythema, herpes, and the exanthematous eruptions.
These, with leprosy and certain rare hypertrophies of the
skin, need not be discussed here. With regard to others,
it is necessary to mention only the peculiarities they
present when occurring in this situation.
Eczema is caused by keeping the eye bandaged, by
overflow of tears in conjunctival or corneal disease with
excessive lacrimatiou ; or it may occur quite apart from
ocular disease. It may be treated by careful cleansing
with warm water and a non-irritating soap, or borax solu-
tion, and then dusting with a mixture of equal parts of
oxid of zinc, lycopodium and starch in impalpable
powder; or if the surface be quite dry, zinc ointment
may be applied daily, taking care to remove the old
thoroughly before a fresh application. In chronic cases
other recognized treatment for eczema may be required.
Fissures of the external canthus (rhagades) arise
under the conditions which cause eczema ; especially if
there is tight closure of the lids, and wrinkling of the
skin near the canthus on account of photophobia. On
stretching the folds apart, one or more elongated raw
surfaces appear. The condition aggravates a tendency to
blepharospasm. The raw surfaces should be touched with
silver nitrate, either in stick or strong solution. In an
obstinate case it may be worth while to do canthotomy.
Toxic dermatitis (Rhus Poisoning, Dermatitis Vene-
nata, and Drug Eruptions}. — The poison oak, and poison
ivy are capable of causing a violent inflammation of the
skin, in certain susceptible persons, even without actual
contact. They are most virulent in the spring and early
summer. The lesions are not confined to the lids, but the
swelling there may be so great as to completely close
them. There is intense itching and burning, and the
skin may be dotted with small papules or vesicles. The
treatment includes careful protection of the surface, with
soothing lotions.
452 DERMATITIS.
A few patients in whom the mydriatics cause conjunc-
tivitis may also suffer from violent dermatitis, with heat,
great redness and swelling, especially of the lids. The
condition quickly improves on withdrawal of the drug.
In toxic dermatitis, the important point is to recognize the
cause, usually through the history of the case.
Erysipelas usually attacks the lids by extension from
other parts of the face. It causes great swelling, the
surface being red and tense. It is distinguished from
other diseases of the lids, by the general symptoms of ill-
ness. When attended by deep suppuration it may cause
orbital abscess, or blindness through optic neuritis, or
atrophy from pressure, or thrombosis of the retinal
vessels, or glaucoma. The treatment is that of erysipelas
elsewhere ; with hot fomentations, and early free incisions
if there be orbital cellulitis.
Herpes zoster (zona, shingles) in the region of the
ophthalmic branch of the fifth nerve is of special import-
ance because of the strong tendency to involve the cornea
and iris, especially when vesicles form on the side of the
nose. It is sometimes mistaken for erysipelas, but should
be easily recognized by the distribution of the eruption
limited to that of the nerve, and always limited sharply
at the median line. The characteristic neuralgic and
burning pain may begin before the eruption, and may
last for months afterward. Motor nerves of the region
may also suffer. The eruption begins with groups of
bright red spots on which vesicles form in a day or two,
which later dry up. They may leave permanent scars,
which, years later, by their distribution, furnish sufficient
basis for a positive diagnosis.
The vesicles should be dusted with an emollient powder,
and carefully protected from rupture. Opium or acetan-
ilid may be given internally to relieve pain, and tonics,
rest, and hygienic measures employed to build up the
general health.
Mollusctim (molluscum contagiosum or epitheliale) is a
rounded dingy white or red tumor, originating in a seba-
ceous gland, sometimes as large as a pea, with a dark
DISEASES OF THE LIDS. 453
central opening, from which white cheesy contents can be
squeezed out. These tumors may occur in great num-
bers all over the body. The disease occurs in marked
endemics and is probably contagious. The treatment
consists in excising each individual tumor.
Warts and horn-like growths of epithelium occur
in the lids ; the latter sometimes attaining the length of
half an inch or more. They should be excised.
Xanthelasma (xanthoma, vitiligoidea) appears on the
skin of the lids after middle life, as slightly elevated, flat,
yellowish patches, compared to the appearance of wash-
leather, symmetrically placed on the two sides of the face,
and slowly increasing in area until they may cover the
greater part of the lids. The affected skin can be excised
to avoid the disfigurement, but the patch may recur. It
is harmful in no other way.
Militim is a minute, white, rounded elevation of the
surface due to a sebaceous cyst. Its removal (for cos-
metic reasons only) may be effected by digging out the
cyst with a needle, or puncturing it and touching it with a
caustic ; or by electrolysis.
Spontaneous gangrene of the skin of the lids is a
rare disease. It may recur, and may prove fatal.
Syphilis. — The primary sore may occur upon the lids,
infection being carried there by the tongue or fingers.
It occurs as a rounded ulcer with an extremely hard base,
running a slow course with very little pain for the extent
of the lesion, with swelling and induration of the preauricu-
lar glands. The ulcer should be kept clean, and as soon
as the diagnosis is confirmed, anti-syphilitic treatment
must be instituted.
The various eruptions of secondary and hereditary
syphilis may appear on the lids. Occasionally an ulcer
due to the breaking down of a gumma is met with after
other manifestations of the disease have passed away. It
is liable to be mistaken for lupus or rodent ulcer. When-
ever such an origin for the sore is possible, anti-syphilitic
treatment should be thoroughly tried. The influence of
454 SYPHILITIC LESIONS.
syphilis in causing tarsitis has been noted. It may also
cause falling of the eyebrows or lashes.
DISEASE OF THE LASHES AND EYEBROWS.
The hairs here as elsewhere, may become decolorized
or whitened (canities, poliosis), or fall spontaneously (alo-
pecia). More frequently the lashes are rendered un-
healthy, distorted or destroyed by inflammation of the lid
involving their roots.
Pediculosis (Pkthiriasis dlioruni). — The pediculus
pubis or crab louse is sometimes found on the eyelashes.
The nits or ova appear as numerous pear-shaped yellowish
bodies 1 mm. or less in length, each glued fast to a hair.
The adult louset is 1 or 2 mm. long, flat, oval, gray in
color, and lying close to the skin is much more difficult to
see. They are quickly killed by careful cleansing of the
part, and rubbing in the ointment of oxid of mercury 1
to 60 or stronger.
Tlichiasis ; DistichiasiS. — Displacement of the eye-
lashes becomes of practical importance when it is such
that they come in contact with the cornea or conjunctiva,
and so become a source of irritation. Distichiasis is
strictly the condition in which an extra row of lashes on
the inner lid-margin, turn toward the eye while all the
other lashes are normally directed. Trichiasis is a con-
dition in which the lashes are wrongly directed against
the eye, but there is no inversion of the lid-margin.
Practically the two have the same significance, and in
most cases trichiasis is essentially a commencing entro-
pion.
Symptoms. — In young children the lashes of the
lower lid are sometimes turned in against the eyeball.
Apart from this it is more often the lashes of the upper
lid that are misplaced. The rubbing of the hair against
the cornea or conjunctiva causes redness, lacrimation,
burning and the feeling of a foreign body in the eye ; or
it may cause opacity or vascularity of the cornea, or con-
junctivitis with purulent discharge. The efforts to get
DISEASES OF THE LIDS. 455
relief by forcible closure of the eyes, may make matters
worse by turning in additional cilia. After removal of
the offending hairs the eye is better until they grow again,
when the symptoms are renewed.
Diagnosis. — Ingrowing hairs should be thought of in
any case of chronic or recurring conjunctiva! irritation,
and a careful search made for them. Often they are
small, and of a light color, and very difficult to see.
They are best discovered by oblique illumination, and
with the binocular magnifier.
Treatment. — If few, the patient may prefer to simply
have the displaced lashes pulled out, as often as they get
long enough to make trouble, or they may be permanently
removed by electrolysis. When the number of displaced
lashes is large, some such operation as is recommended
for entropion should be done.
DISTORTIONS, DISPLACEMENTS, AND ADHESIONS OF
THE LIDS.
Untropion, inversion of the lid-margin, may be pro-
duced by spasmodic contraction of the orbicularis muscle,
spasmodic entropion. This is favored by redundancy of the
skin in childhood, or swelling of the lids after injury, or
operation about the eye ; by relaxation of the skin in old
age, or by loss of support of the lids by the eyeball as
from phthisis bulbi, atrophy of the orbital fat, or enuclea-
tion. It may be brought about by any cause of ocular irrita-
tion ; it often arises while an eye is bandaged ; and, once
started, tends to increase the irritation and so to perpetuate
itself.
Entropion is also associated with cicatricial changes in
the lids, and with shrinking of the conjunctiva from
chronic disease, especially trachoma. This is called
organic or cicatricial entropion. It is usually increased
by orbicular spasm. To recognize the presence and ex-
tent of an entropion the eyes should be carefully inspected
without touching them. Even a light touch on the lids
may be sufficient to draw the lashes away from the eye-
ball.
456 ENTROPION.
Treatment. — Spasmodic entropion may be relieved by
removal of the exciting cause ; or by keeping the lashes
everted for a time by a strip of plaster, or by painting
the carefully dried skin with collodion, coat after coat ;
or by keeping a fold of skin pinched up with forceps. If
the above measures fail, some operation must be per-
formed. In children canthotorny may be practiced. In
other cases, one of the operations described in Chapter
XIX may be resorted to for the upper lid. For the
lower lid, caustic potash may be applied along a line
parallel with the lid-margin, and 4 mm. from it to pro-
duce eversion by the eschar it causes.
Uctropion. — Eversion of the lid so that the conjunc-
tival surface is exposed, may result from swelling of the
conjunctiva (acute ectropion). The effect is increased by
exophthalmos, spasm of the orbicularis muscle, and ob-
struction of the conjunctival veins, so that when restored
the lid promptly turns out again, weakness or paralysis
of the orbicularis muscle allows the lower lid to fall away
from the eyeball and the conjunctiva to become exposed
(paralytic ectropion).
Organic ectropion, or dragging away of the lid-margin
from its normal position by cicatricial contraction, occurs
after burns, abscesses, sloughing, or wounds of the lids and
neighboring parts. The exposed conjunctiva becomes con-
gested or hypertrophied ; and the secretions, with the tears,
no longer passing through the everted punctum, dry upon
the exposed conjunctiva and the neighboring skin, and
tend to aggravate the trouble.
Treatment. — The removal of the cause may be suffi-
cient in acute ectropion, or incision, or excision of a part
of the everted conjunctiva may be needed. Paralytic
ectropion often requires no treatment, or the lacrimal pas-
sages may require attention. Or it may, as does organic
ectropion, require an operation which must be specially
planned to meet the needs of the case (see Chapter XIX).
I/agOphthalmoS (Patsy of the Orbicularis). — Inability
to close the eyes is present in severe organic ectropion ;
or may be due to congenital defect, exophthalmos, staphy-
DISEASES OF THE LIDS. 457
loma, or paralysis of the seventh (facial) nerve. It
may be associated with oculomotor palsy when other
parts of the facial nerve escape. The pimcta not being
properly applied to the eyeball, epiphora results. Strong
eifort to close the eye causes no wrinkling in the affected
lids, but causes the eye to roll upward. The turning up
of the cornea usually secures it sufficient protection in lag-
ophthalmos to prevent its destruction, but it may suffer
from exposure.
Blepharospasm. — Annoying twitching of the lids,
often so slight as to be unnoticed except by the patient, is
a symptom that may arise from the instillation of physos-
tigmin, conjunctival irritation, eye-strain, or lack of nerve
tone, as from loss of sleep. It is of less importance than
the patient often thinks it, and is commonly relieved by
removal of the cause ; but in some patients is apt to
recur.
Spasmodic contraction of the lids, usually with those
of other muscles of the face or movements of the head,
are seen in chorea. Excessive winking is seen as a kind
of habit-chorea. It is mostly, at least in the beginning,
associated with eye-strain, or local irritation. Spasmodic
closure of the lids follows the entrance of an irritant into
the eye, or attends corneal disease, or fissure of the skin
near the outer canthus. In rare cases, it is a reflex of
irritation in the nose or about the teeth. Such cases are
commonly cured by removal of the cause.
The most serious cases are those of tonic spasm without
discoverable local cause. The closure of the lids may
last but a few minutes, or for hours, or even weeks ; and
has sometimes been succeeded by temporary blindness.
Section of the nerve may afford relief.
Ptosis, or inability to raise the upper lid, may be
hysterical or due to paralysis of the levator muscle, swell-
ing or hypertrophy of the lid or neighboring parts, offer-
ing a mechanical obstacle, or to habitual closure of one
eye to avoid blurred vision, or to congenital defect.
Paralytic ptosis is usually associated with other evi-
dences of paralysis of the oculomotor nerve, and is due
458 PTOSIS.
to syphilis, rheumatism, pressure of the nerve by hemor-
rhage or a new growth, or to disease of the central nervous
system. The completeness of the paralysis may be judged
by noting if on looking up there be any retraction of the
skin where it passes from the lid to the upper margin of
the orbit where normally such retraction occurs. The
treatment must at first depend on the cause. But if after
many months no power is recovered in the paralysed
muscle, the trouble may be somewhat remedied by opera-
tion (see Chapter XIX), unless the uncovering of the eye
will cause diplopia from other third nerve palsies.
Congenital ptosis is often hereditary and associated
with other congenital defects. In a few cases where the
lid cannot be raised alone, it can be raised in association
with movements«of the lower jaw. Congenital ptosis
may be due to hypertrophy of the lids. It usually allows
the patient an imperfect use of his eyes. It can only be
remedied by operation, or mechanical support for the lid.
UpicanthtlS is a fold of skin stretching from the brow
to the side of the nose, and covering more or less com-
pletely the inner canthus. It is congenital ; often asso-
ciated with ptosis. and minor degrees of it are frequently
seen in early childhood. Usually with development of
the nasal bones the deformity disappears. It may be les-
sened by removing from the bridge of the nose a piece of
skin shaped like a section of a convex lens, and then
bringing together the two sides.
Blepharophimosis, or narrowing of the palpebral
fissure, may be congenital, or due to adhesion of the lids
at the outer cauthus after ulceration, or to cicatricial con-
traction of the lids and conjunctiva from trachoma. It
interferes with eversion of the lids for local applications ;
and greatly increases the injurious influence of rough cica-
tricial lids upon the cornea. On these accounts it is often
best to remedy it by canthoplasty (see Chapter XIX).
Anchyloblepharon, or union of the upper and lower
lids at a point between their extremities, may be congenital,
in which case it may be relieved by simple division. But
more frequently it is due to burns or similar injuries, and
DISEASES OF THE LIDS. 459
is associated with symblepharon (see page 269) ; and is to
be treated by such operations as the symblepharon may
require.
SWELLINGS AND TUMORS OF THE EYELIDS.
Udema. — The loose subcutaneous tissue and redun-
dant skin of the lids permit of the rapid accumulation of
serous fluid in large quantities, and its equally rapid dis-
appearance. A small stye or slight injury will sometimes
be followed by enormous swelling ; and severe intra-ocular
disease or injury may cause similar swelling. Renal dis-
ease, heart disease, malaria, arsenical poisoning etc., cause
marked edema of the lids, which is increased while lying
down and diminished when in the erect position. It may
be caused by acute indigestion. In some persons it is a
chronic or recurring condition of obscure origin, which
gives annoyance for years. It may arise from syphilis.
Emphysema of the lids and orbit arises as part of a
more general emphysema, or through the entrance of air
from the air-cavities of the head into the subcutaneous
cellular tissue, commonly through fractures of the bones
containing these cavities. The air is forced into the tis-
sues through sneezing, and blowing the nose ; and gives rise
to a soft elastic crackling swelling that may increase with
alarming rapidity, but subsides when the forcing of the
air into the tissues is stopped.
Chalasjion (tarsal cyst] is a small firm rounded tumor
of the lid, closely attached to the cartilage, and over
which the skin moves freely. It develops slowly, often
without inflammation, and without attracting the patient's
attention until it has attained some size. Two or more
may be present at the same time. It is most frequent in
early adult life. Often mild inflammatory symptoms are
present in the later stages. It grows for several months,
becoming the size of a pea or larger. It arises from a
meibomian gland, and consists largely of granulation-
tissue surrounded by a membranous wall. It is not a
retention-cyst, but its contents may undergo softening so
460 CHALAZION.
that it becomes an encysted abscess. It is annoying on
account of its appearance, and the sense of weight or
stiffness it causes in the lid.
The conjunctiva opposite the growth shows a spot of
lighter yellow, or gray color ; and, if undisturbed, after
many months the chalazion may open through this spot,
discharge its fluid contents into the conjunctival sac, and
slowly contract. After it opens, the granulation-tissue is
apt to fill the cavity and may protrude on the conjunctival
surface. A small chalazion may disappear spontaneously
without opening, or at an early stage its contents may be
pressed out.
Treatment. — This is operation by incision or excision,
(see Chapter XIX), and, if either be present, the removal
of eye-strain or chronic conjunctivitis to prevent a recur-
rence.
I/ipoma. — Accumulation of fatty tissue in the lids is
rare. It may occupy the whole or a limited portion. If
it be unsightly or interfere with the lid-movements, it
may be excised. Fibroma, a firm tumor, often present at
birth and enlarging years later, occurs in the lids. Netl-
roma and cysticerctlS of the lid have been reported.
Dermoid, lymphoid, and other tumors of the orbit fre-
quently involve the lids.
Angioma (nevus, vascular tumor} of the lid may vary
from the superficial capillarity which makes a " mother's
mark " to a collection of large vascular sinuses having a
definite wall (cavernous anglomd), or masses of large
dilated vessels (telangiectasis), which may extend deeply in
the orbit, or be associated with abnormalities, or the
retinal or choroidal vessels. Such growths appear at or
shortly after birth, and often tend to increase in size, at
least for a time. A few spontaneously disappear.
Diagnosis. — A vascular tumor can be recognized by
its variability in size. When the child cries, or is held
head down, the tumor noticeably enlarges. By firm
pressure it may be reduced, or caused to disappear. If
not thus reducible, it is commonly connected with an artery
of some size, and exhibits decided pulsation.
DISEASES OF THE LIDS. 461
Treatment. — For a superficial nevus cauterizing with
nitric acid, or sodium e thy late, may be resorted to. The
caustic is applied with a glass rod. The eschar must be
left undisturbed until it separates spontaneously, the
caustic being applied repeatedly if needed. Vaccination
of the nevus has affected its removal. A larger or deeper
angioma, if diminishing, should be let alone ; and if
stationary, should be attacked with great caution. But
if clearly increasing, it should be promptly excised, or
ligated by multiple ligatures, or subjected to electrolysis.
Excision is on the whole most satisfactory ; but the sur-
geon should always start prepared for a serious operation.
Electrolysis may be afterward resorted to for small por-
tions that escape excision.
Sarcoma. — Primary sarcoma may occur in the lids.
If not pigmented, it somewhat resembles chalazion, for
which it has been mistaken. It should be promptly and
completely excised ; and even then may recur.
lyllpus (tuberculosis of the skin) occurring on the face
may involve the eyelids, and may extend thence to the
conjunctiva. It must be borne in mind in connection with
the diagnosis of syphilis and epithelioma.
Epithelioma (rodent ulcer, Jacob's ulcer) begins most
frequently on the margin of the lower lid, as a flat thick-
ening of the skin most prominent and hard at the mar-
gins. It begins usually after middle life, and may remain
with no change except a slight extension of its surface for
many years. Then the center ulcerates, and becomes
covered with a brownish crust. After this the ulceration
keeps pace with the deposit, slowly extending until it
may destroy a large portion of the face without involving
the lymphatic glands, or giving rise to secondary de-
posits.
Diagnosis. — In a typical case the appearance is char-
acteristic, but local irritants or attempts at treatment may
disguise it ; and syphilitic ulceration might be mistaken
for it. The syphilitic ulcer develops more rapidly, and
has softer, punched-out edges. Where there is the slight-
est doubt, energetic antisyphilitic treatment should be
462 EP1THELIOMA.
tried. Lupus starts in early life, usually on some other
part of the face, extends by the formation of isolated
nodules which later coalesce, has softer and less definite
edges, is attended with more redness and inflammation of
neighboring parts, lacks the characteristic ulcer of epi-
thelioma, and runs even .a slower course. Epithelioma
of the lids sometimes assumes the form seen elsewhere,
forming a thick mass that breaks down at the center and
extends with comparative rapidity.
Treatment. — Large masses should be excised if practi-
cable, or the thickness of the growth reduced by curetting.
Remaining masses, small tumors, recurrences, and all
inoperable growths should receive treatment by the X-ray.
The tube used should have a spark-gap of 1 to 2 inches.
It should be brought as close as possible to the tumor, and
the eye and healthy parts shielded from the ray. Many
cases can thus be permanently cured, and nearly all can
be retarded in their course.
Burns of the lids, if small, heal quickly and cause no
trouble, but if extensive they cause permanent deform-
ity of the lids, through cicatricial contraction. They
should be treated by exclusion of air, either by a dressing
of carbolized oil and lime-water, or by lint soaked in a
solution of borax or sodium bicarbonate. After two or
three days the surfaces should be cleansed once daily and
dusted with iodoform. Extensive granulating surfaces
should be covered with skin -grafts.
Other injuries of the lids are considered in Chapter
XVII.
DISEASES OF THE LACRIMAL PASSAGES.
Epiphora (Stitticidium Lacrimarum, Watery Eye). —
The tears secreted to keep moist the surface of the cor-
nea, and remove irritants from the conjunctival sac, pass
normally through lacrimal passages into the nose.
Failure of the lacrimal drainage-system to remove the
tears fast enough causes them to accumulate in the eye,
and run over the edge of the lid.
DISEASES Of THE LACUIMAL APPARATUS. 463
The amount of lacrimal secretion varies greatly in
health, in response to nerve-impulses sent to the gland. It
can be enormously increased, as by emotion, exposure of
the eye to wind, dust, or irritating vapors, or disease, par-
ticularly inflammation of the cornea or iris. The drainage-
system, parts of which are little more than tubes of
capillary size, failing to dispose of the increased secretion,
overflow results — excessive lacrimation (reflex epiphora).
Epiphora of this kind may result from irritation of the
lacrimal passages themselves, or even of the nose. It
may also arise from retinal impressions, as a bright flash
of light, or from the effect of moderate light upon an
over-sensitive retina.
Every case of epiphora should be carefully considered,
with reference to its possible origin in one of these sources
of reflex action. Even where there is obvious organic
disease of the lacrimal passages-, this in itself raises a
presumption of accompanying reflex epiphora, and the
share this has in the symptoms should be carefully con-
sidered.
Treatment. — To remove an excessive reflex as to light
or the rush of air in riding a bicycle, the eye must be
accustomed to the stimulus, and any excessive irritability
of the nervous system reduced as far as possible. The
treatment of epiphora due to obstruction of the lacrimal
passages will be considered in connection with the various
diseases which cause it.
Closure (Atresia) of the Punctum. — Closure of
the punctum may be congenital, or may arise from the
eversion, and non-use of the punctum, or from disease or
injury to the parts. It may affect one or more of the
puncta. If the canaliculis is normal, the punctum may
be opened, and dilated with a fine-pointed probe. An
ordinary pin with a good point is well adapted to the
purpose. The proper position for the punctum having
been determined, this point should, with a slight rotary
motion, be thrust into it, until it is well dilated. The
dilatation may need to be repeated a few times to make
it permanent. Closure of the punctum with closure of
464 CLOSURE OF THE PUNCTUM.
the canaliculus must be treated as for the latter con-
dition.
Displacement of the Punctum. — The normal
puuctum is directed toward the eyeball where it reaches
and draws in by its capillary action the thinnest film of
tears. When the punctum is located on the edge of the
lid instead of on the inner margin, or when the lid is
somewhat everted, the tears before reaching it must
accumulate to an abnormal extent, and perhaps flow over
the lid-margin. This is a common cause of epiphora.
Misplacement of the punctum in the lid may be congeni-
tal. Eversion may be due to any cause of ectropion or
lagophthalmos, to slight thickening and rounding of the
lid-margin in blepharitis, or to swelling in conjunctivitis,
contraction of the skin of the lid near the punctum, or
senile relaxation of the lower lid. It may be quite
sufficient to cause serious epiphora, although there is
no displacement of the lid noticed on casual inspec-
tion.
Treatment. — If the cause of the eversion of the punc-
tum can be removed, as by cure of conjunctivitis, bleph-
aritis, or facial paralysis, or restoration of the lid-border
to normal position in ectropion, this may cure the ever-
sion. If this cannot be done, it is customary to slit the
canaliculis. (See Chapter XIX.)
Obstruction of the canaliculus may occur through
stricture, inflammatory swelling of its lining membrane,
pressure from without, by polypi, or from a foreign body,
as an eyelash, or a "tear stone" (dacryolitti) within it.
The latter is a mass, consisting largely of calcium phos-
phate, formed by the presence of a lepfotkrix, a filament-
ous form of bacteria. Or the canaliculus may be absent as
a congenital anomaly, or destroyed by traumatism.
Treatment. — Inflammatory swelling may be reduced
by appropriate treatment to the adjoining conjunctiva
and the lining membrane of the lacrimal sac, which are
always involved. Stricture may be dilated by passing
successively larger probes from 1 to 4 or 6 (see Chapter
XIX); although a permanent cure usually requires
DISEASES Of THE LACRIMAL APPARATUS. 465
slitting of the canaliculis, which is also necessary when
foreign bodies must be extracted.
Obstruction of the Nasal Duct. — This is com-
monly due to partial or complete closure, through nasal
disease, of the duct where it enters the nose, to inflam-
matory swelling of its lining membrane, to fibrous strict-
ure usually situated at the upper end, or to disease of the
bony walls surrounding it. It always causes epiphora,
with swelling of the lacrimal sac and regurgitation of
its contents into the conjunctival sac under pressure.
If the obstruction continues any length of time, it is
attended with inflammation of the lining membrane of
the sac, which is usually catarrhal but often becomes
purulent. The regurgitation of the contents of the sac
extends the inflammation to the conjunctiva, setting up
and keeping up a chronic conjunctivitis, often called
lacnmal conjunctivitis.
Diagnosis. — The swelling of the sac is seen as an
ovoid swelling {lacrimal tumor, mucocele), situated at the
side of the nose and extending more below the canthus
than above. This tumor varies in size from time to time,
and may entirely disappear under firm pressure which
forces out the contents of the sac. The situation of the
swelling, and its diminution with the regurgitation of
its contents into the conjunctiva, are very characteristic.
In some cases a portion of the contents may, under pres-
sure, be forced into the nose. An important point is to
try whether, by means of the lacrimal syringe, fluid can
still be forced through the obstructed duct into the nose.
Treatment is directed toward re-establishing a suffi-
cient passage from the lacrimal sac into the nose. In
some cases treatment of the nose, as the removal of con-
stricting bands or scars, or hypertrophy of the lower tur-
binals behind which the duct opens, will be sufficient.
In other cases, cure of an inflammation of the mucous
membrane of the sac and duct may reopen the latter by
reduction of the swelling. For this purpose the passages
should be regularly syringed out with a solution of pro-
targol or argyrol, and the patient instructed to fre-
30
466 OBSTRUCTION OF THE NASAL DUCT.
quently empty the sac by pressure upon it. Any ab-
normality of the puncta or canaliculi which would inter-
fere with the flow of fluid through the duct must be cor-
rected, for the health of the lacrimal passages cannot be
secured without the free flow of tears through them. The
above measures will often give permanent relief, if the
obstruction is still incomplete or intermittent.
For the more serious cases it is necessary to slit a cana-
liculis, preferably the upper, unless the lower is displaced
or obstructed, and to probe the duct (see Chapter XIX).
The passage having thus been opened the lumen must be
maintained, either by the repeated passing of the probe,
or by the continuous wearing of a style until the tendency
to re-contraction of the stricture has been fully overcome.
The probes used slftmld be as large as can readily be passed,
3 mm. in diameter or even larger. But the re-establish-
ment of the lacrimal passages by probing is a very serious
undertaking, to be reserved for skilled hands and for
exceptional cases. Often the process can be hastened by
cutting the stricture (Chapter XIX), followed by the in-
sertion of a style of about 3 mm. diameter.
Sometimes absorption is hastened by connecting the
probe, while in situ, with the negative pole of a galvanic
battery, and passing through it a current of about 2 mil-
liamperes for 2 to 5 minutes. Disease of the bony walls
of the lacrimal canal may require removal of diseased
bone. In such cases, when the tissues are greatly altered
by lacrimal abscesses, or when the treatment by probing
cannot be carried out for a sufficient length of time, it is
best to excise or completely obliterate the lacrimal sac
(see page 542).
Prognosis. — Lacrimal obstruction so * serious as to
require operative treatment is not followed by restoration
of the passages to normal. The slit canaliculis never
takes the tears from the eye quite as nicely as the normal
passage ; and permanent maintainance of a capillary pas-
sage cannot be hoped for. Relative cure is obtained by
establishing an abnormally large and patulous canal, more
likely than the normal canal to receive irritants both from
DISEASES OF THE LACRIMAL APPARATUS. 467
the conjunctiva and from the nose. Through such a canal,
air and nasal discharges, may be blown into the eye, in
blowing the nose. Relief may be obtained from the more
serious effects of lacrimal obstruction ; but only by pain-
ful and tedious measures.
I/acrimal Abscess. — Allusion has been made to
the chronic inflammation of the lacrimal passages that
attends obstruction. If this continues there is great
liability to more acute inflammation of the sac, acute
dacryocystitis, with infection of the surrounding cellu-
lar tissue, and the formation of an abscess. The tumor
caused by distension of the sac becomes enlarged, red, and
painful, tending to extend rather downward ; and if let-
alone softens and breaks, establishing a false vent for the
contents of the sac, a lacrimal fistula.
Treatment. — The canaliculus should be slit so as to
make quite a free opening into the sac, and if near the
point of breaking, the abscess may also be opened exter-
nally. Both sac and abscess cavity are then to be
thoroughly cleansed with hydrogen dioxid solution ; and
after a day or two when the extreme soreness of the parts
has somewhat abated, the passage should be re-established
into the nose. Only the removal of the obstruction or
the complete destruction of the sac will secure the closure
of a lacrimal fistula or the permanent healing of the
parts.
DISEASES OF THE LACRIMAL GLAND.
Inflammation (dacryo-adenitis) is rare, and commonly
secondary. It lias been associated with mumps, syphilis,
gonorrhea, rheumatism, and septic absorption. Usually
it is chronic, giving rise to redness and swelling of the
upper lid, and a firm tumor which may be felt on palpa-
tion at the upper and outer margin of the orbit, with
injection of the adjoining conjunctiva. Acute inflamma-
tion may go on rapidly to suppuration, with enormous
swelling of the lids.
Chronic inflammation should be treated, by attention to
any general disease, with mercury and iodids internally,
468 DACRYO-ADENITIS.
and cautious massage of the part with mercuric oxid
ointment. Acute inflammation requires hot applications
and early incision. If a fistulous opening be found in the
skin of the lid, it may be transferred to the conjunct! val
surface, by a ligature passed into and around it, tied on
the conjunct! val surface and tightened until it cuts
through.
Hypertrophy, or enlargement of the gland, may be
congenital or may follow syphilis. It is sometimes so
great as to displace the eyeball and cause great deformity.
Prolonged antisyphilitic treatment should be tried, but
if it fails, extirpation may be necessary.
Dislocation of the lacrimal gland causes it to be
seen and felt in the lid below the orbital margin. It may
be spontaneous «r traumatic. In children it sometimes
follows a fall on the face, with or without a wound of the
brow. The gland should not be hastily excised.
Cyst of the lacrimal gland (dacryops) is due to-obstruc-
tion of one or more of its ducts. It appears as a bluish
translucent tumor, beneath the conjunctiva of the upper
lid, sometimes varies in size, the obstruction being incom-
plete, and is notably increased by anything that provokes
the secretion of tears. It may be incised, and the incision
repeatedly opened until its edges have healed. Or a
suture may be passed through its walls and allowed to cut
itself out.
Tumors of the lacrimal gland are rare. Chalky con-
cretions sometimes form in it ; and adenoma, sarcoma,
myxoma, epithelioma, osteochondroma, lymphoma, and
hydatid cyst of the gland have been met with.
DISEASE OF THE ORBIT AND ORBITAL WALLS.
Orbital Cellulitis (Abscess or Phlegmon of the Orbit).
— Symptoms. — Inflammation of the cellular tissue of
the orbit begins with deep orbital pain, headache, limita-
tion of ocular movements, protrusion of the eye, swelling
and dusky redness of the lids and conjunctiva. Retinal
hemorrhage, and neuroretinitis to be followed by optic
DISEASES OF THE OKBIT. 469
atrophy, may attend inflammation behind the globe ; and
sloughing of the cornea may occur when there is great
swelling at the front of the orbit. Panophthalmitis may
occur. In the more violent cases, a general chill occurs
at the outset, followed by fever, and marked evidence of
general illness.
Course and Varieties. — It may develop in facial
erysipelas, in which case both orbits are mostly involved,
may follow excessive exposure to cold or acute fevers,
especially typhoid and scarlatina, may arise by metastasis
in pyemia, or from local injury, panophthalmitis, periosti-
tis of the orbit .or similar disease of the neighboring
parts.
Diagnosis. — Orbital cellulitis must be distinguished
from panophthalmitis by the absence of opacity of the
dioptric media, or other evidence of suppuration within
the globe ; from purulent conjunctivitis in which there is
more conjunctival discharge and no exophthalmos or
limitation of ocular movements ; and from thrombosis of
the cavernous sinus, which is marked by great swelling in
the orbit, with pain and obstruction of the circulation,
but which may be distinguished by the presence of cere-
bral symptoms, palsies of certian ocular muscles, before
general immobility of the eyeball occurs, and by the
pre-eminence of the venous element in the hyperemia.
But the diagnosis might be complicated by the superven-
tion of the orbital inflammation on either of the other
conditions mentioned.
Treatment. — The cellulitis should be carefully at-
tended to, especially if it is a local suppuration, or perios-
titis. The patient should be put to bed, and full doses
of tincture of chlorid of iron, with moderate doses of
quinin and such other general treatment as may be indi-
cated. Blood should be taken from the temple freely in
the early stage. Hot fomentations should be applied at
short intervals. As soon as there is evidence of any pus-
collection, it should be given free vent. But earlier than
this, if the swelling is very great, deep incisions should
be made near the orbital margins. If practicable, these
470 ORBITAL CELLULITIS.
should be made from the conjunctiva, being preceded, if
necessary, by canthotomy. But if necessary they should
be made through the lids, avoiding the position of the
oblique muscles. In facial erysipelas, additional incisions
may be required in the lids. If panophthalmitis super-
venes, an incision should be made through the cornea
that will let out all the contents of the globe ; or the eye-
ball may be enucleated.
The incisions should be washed out with hot antiseptic
solutions, and the fomentations continued until the swell-
ing begins to subside.
Prognosis. — Orbital cellulitis endangers the sight
through ocular inflammation and optic atrophy ; and it
endangers life through thrombosis or extension into the
cranium, especialry when due to erysipelas.
Inflammation of the oculo-orbital fascia (ten-
onitis) may be caused by gout, rheumatism, influenza, in-
flammations of the eyeball, or injury, especially operation
on the ocular muscles. It is indicated by swelling of the
lids, particularly the upper, pain on the movement of the
eye, and conjunctival edema which may be limited to a
small portion of the membrane. If not caused by injury
of the orbital tissue it is not attended by suppuration,
but it gives rise to extensive fibrous adhesions of the
globe, which hinder enucleation of the eye if this becomes
necessary.
It should be treated by rest of the eyes, and dry heat
or occasional hot fomentations. Internally iodids, salyci-
lates, potassium acetate, or colchicum may be given, with
saline laxitives, and anodynes, if necessary. For sup-
purative cases, free drainage for pus, and frequent hot
irrigations or fomentations, are to be employed.
Periostitis, Caries and Necrosis. — Acute general
periostitis of the orbit causes the symptoms of orbital
cellulitis due to it. Chronic periostitis gives rise to
thickening of the periosteum, which, if not deeply situ-
ated, may be felt as a hard immovable swelling, — fibrous
thickening, or a soft fluctuating mass — abscess. There is
deep-seated pain in the orbit, and may be tenderness to
DISEASES OF THE ORBIT. 471
pressure. There may or may not be exophthalmos or
other displacement of the eyeball. The disease is usually
due to syphilis, tuberculosis, disease of the neighboring
cavities, or traumatism, the latter often acting as an ex-
citing cause. If suppuration occurs, the abscess slowly
makes its way to the surface, the skin becomes reddened,
and upon the opening of the abscess a sinus is discovered
with bare carious bone at the bottom. In rare cases a con-
siderable fragment of bone may be present. The fistula
thus established tends to become chronic. If the open-
ing is near the orbital margin, the skin becomes firmly
adherent to the bone, causing deformity of the lids. If
the sinus opens into the conjunctiva, its origin is probably
quite deep in the orbit.
Diagnosis. — Chronic periostitis starting deep in the
orbit may cause no distinctive symptoms until it extends
well forward. Near the orbital margin the swelling it
causes might be confused with gumnia of the orbit, a
mistake usually not serious, since syphilis is the most fre-
quent cause of periostitis. Where a sinus exists, care
should be taken to make sure that it is not caused by a
foreign body, lodged in the orbit unknown to the patient,
at the time of an injury to which the periostitis is ascribed.
Careful search must also be made for a cause of the disease
in the neighboring sinuses connected with the nose.
Treatment. — Periostitis without suppuration should be
treated with mercury and large doses of potassium iodid,
or cod-liver oil, iodid -of iron, etc., or alteratives and
general tonics. Any abscess should be freely opened as
early as possible ; and a drainage-tube introduced or the
cavity packed with iodoform gauze, and after that washed
out at regular intervals, with hydrogen dioxid or other
antiseptic. Dilute hydrochloric acid may be injected in
the hope of removing carious bone and stimulating granu-
lations. Curetting the carious surface, or attempts to
remove necrosed bone should be deferred until the surgeon
has learned pretty accurately the limits of the disease,
and until a free external opening is established.
Enophthalmos. — Sinking of the eyeball in the orbit,
472 EXOPHTHALMOS.
causing it to appear smaller than its fellow, occurs from
emaciation, traumatism, paralysis of the sympathetic, and
possibly other nerve-lesions.
Exophthalmic goiter ( Graves' or Basedow's disease)
is not essentially a disease of the eyes, but its ocular
symptoms and complications are of such importance that
it very often is brought to the notice of the ophthalmic
surgeon.
Symptoms. — Along with increased rapidity and irrita-
bility of the heart's action and variable enlargement of
the thyroid, there occurs exophthalmos, which may reach
such high degree that it is impossible for the cornea to
be covered by the lids, and the exposed portion of the
cornea may become vascular, or may ulcerate or slough,
destroying the e^. The protrusion of the eye (proptosis),
however, often appears greater than it really is, on account
of the retraction of the lids. These are habitually
separated more widely than normal (Dalrymph' s sign).
They are incompletely closed in winking, and the interval
between the attempts at winking is irregular, being some-
times much prolonged (Stellwag's sign). On looking down-
ward, the upper lid, instead of normally following the
motion of the globe, remains more or less elevated (von
Graefe's sign). Usually these symptoms are bilateral,
although the exophthalmos may be greater on one side
than on the other. But they may affect but one eye.
Treatment. — The general tonic treatment and regu-
lated life which should be carried out need not here be
dwelt upon. The eyes should be studied as a possible
source of nerve-strain, and treated accordingly. If the
exophthalmos becomes excessive, it may be best for the
cosmetic effect, or to prevent corneal disease, to try to
narrow the palpebral fissure by tarsorrhaphy ; yet even
this may be ineffective. If sloughing of the cornea
occurs, enucleation may be necessary.
Pulsating Exophthalmos. — Under this title are
included cases presenting several distinct pathological con-
ditions, which are best considered together, because the
symptoms they present are so nearly indentical that in
DISEASES OF THE ORBIT. 473
practice it may be quite impossible to decide which con-
dition is present.
Symptoms. — There is exophthalmos, the eye being
displaced forward (and usually a little downward) some-
times so far that the lids cannot be closed over it. Pul-
sation of the orbital contents is sometimes visible, and
always perceptible to touch. A decided bruit is present,
very annoying to the patient, and heard distinctly by the
surgeon over the orbit and the neighboring regions of the
skull. The eyeball by firm pressure may be restored
toward its normal position, but again protrudes when the
pressure is removed. These symptoms are relieved largely
or completely by pressure on the carotids. Vision is often
but moderately impaired ; but some cases show optic
neuritis, and there may be enormous dilatation of the
veins, both of the retina and orbit. The movements of
the eye are limited, the orbital muscles may be quite
paralyzed, and the pupil widely dilated. The bruit is
heard by the patient as a blowing, puffing, buzzing, sing-
ing, whistling, roaring or hammering noise, and is often
accompanied by vertigo. The lids and conjunctiva are
often swollen, and show venous congestion, and the
cornea may become hazy, or ulcerated from exposure.
The whole area supplied by the ophthalmic branch of the
fifth nerve may be anesthetic. A distinct soft pulsating
tumor may sometimes be felt below the brow.
Causes and Pathology. — This condition has been
ascribed to aneurism of the ophthalmic artery, but this
lesion has been found in very few cases. The symptoms
do not occur with unruptured aneurism of the internal
carotid. The most frequent lesion is a laceration of the
carotid artery within the cavernous sinus. This may be
due to traumatism causing fracture of the base of the
skull, in which cases the symptoms develop rapidly
within a few weeks after the injury. It also occurs
spontaneously, usually in elderly women, the symptoms
developing quite suddenly after a feeling of something
having broken within the head. In a few cases, a vas-
474 PULSATING EXOPHTHALMOS.
cular tumor has been discovered in the orbit ; and in some
autopsies no significant lesions have been found.
Diagnosis. — The condition may be closely simulated
for a time by a highly vascular malignant new-growth
in the orbit. But the absence of traurnatism, and the
gradual development of symptoms, with the^ attendant
cachexia, should distinguish the malignant disease. In
trying to fix the cause of the particular case, the feeling
of something giving way, and sudden onset, or the history
of injury with other symptoms of fracture of the base of
the skull, characterize the arterio-venous aneurism of the
carotid and cavernous sinus. In aneurism of the ophthal-
mic artery or vascular growths in the orbit the develop-
ment of symptoms will be more gradual.
Treatment add Prognosis. — The course of this disease
usually extends over several months or years. A few
cases recover spontaneously, more die of rupture of the
arterio-venous aneurism. Compression of the carotid
may lead to cure, and should be tried if practicable. It
is more likely to cure the idiopathic cases, and can some-
times be kept up by the patient himself. If it fail, liga-
tion of the carotid is the most promising measure and
should be tried. A vascular tumor may be treated by
excision or electrolysis.
Angiotnata of the orbit usually extend into the lids
(see page 460).
Dermoid cysts of the orbit are congenital, but de-
velop slowly. They appear most frequently at the inner
or outer upper margin of the orbit. They are smooth,
rounded, elastic, not closely connected with the skin, but
usually with firm connection with deeper structures.
They may be quite small and superficial, or may have
prolongations to the depths of the orbit, or even beyond.
Some idea of the size of the cyst may be obtained from
its behavior under pressure. If superficial, it shows little
change of size ; if deep, the visible portion retreats under
pressure, and the eyeball and other contents of the orbit
are pushed forward. Dermoids require removal on
account of their unsightly appearance. If not very deep,
DISEASES OF THE ORBIT. 475
they should be excised, care being taken to dissect out
the whole sac, to avoid recurrence. Very good results
have been obtained by opening the sac, emptying it, and
placing in it a few crystals of silver nitrate, or injecting
tincture of iodin.
Other Cysts. — Encephalocele is congenital, and ap-
pears at the inner angle of the orbit. It pulsates, and is?
reducible by pressure through passage of the fluid into
the cranium. It should be let alone. The child dies of
accompanying cerebral lesions, or of meningitis from in-
flammation starting in the sac.
Another congenital cyst is that always associated with
extreme microphthalmus or anophthalmus, and developed
from what should have furnished the interior structure
of the eye. This distends the lower lid and may occupy
the whole orbit. In addition there have been found in
the orbit exudation-cysts following hemorrhage, hydatids
and cysticercus.
Orbital tumors, if at all extensive, cause protrusion
of the eye, which, if not too rapid, is accompanied by
compensatory hypertrophy of the lids, particularly the
upper. Such a tumor is usually fixed, although the
movement of the loose tissues over it often gives a decep-
tive sense of movement of the tumor. They may reach
a very large size, and greatly displace the eyeball, with-
out causing complete blindness. Often the character of
the growth can . only be recognized by microscopical ex-
amination. The question of a syphilitic origin should
always be considered, and doubtful cases submitted to
the test of careful anti-syphilitic treatment. Tumors of
the optic nerve are discussed on page 390.
Sarcoma of the several varieties occurs in the orbit.
It may start from the walls of the orbit, or from any of
its contents, or may invade the orbit from neighboring
cavities. The recognized treatment is early extirpation,
although the growth is liable to recur. Generally the
whole of the orbital contents should be removed, and if
the growth be large, it will be well on the following day
to cauterize the orbital walls with chlorid of zinc paste.
476 ORBITAL TUMORS.
The method of Coley of injecting mixed toxins is also
worthy of trial and further development.
Fibroma and fibrosarcoma also occur in the orbit.
Carcinoma invades the orbit secondarily. Lymphoid
growths (lymphama) occur in and about the orbit in cases
of leukemia. Chloroma, a growth of a light green color,
fs also closely connected with leukemia though often
classed as a sarcoma.
Osteoma (ivory exostosis) is a hard, rounded, firmly-
fixed, slowly-growing tumor, that appears usually at the
upper inner angle of the orbit, somewhat back from the
margin. It causes no pain in the early part of its course,
and little disturbance of vision. The growth, commonly
starts from the ethmoid or frontal sinus, and may extend
toward the brain as well as toward the orbit. It is
commonly attached by a comparatively narrow pedicle.
Early removal is the best treatment, though this is
attended with some risk if the growth has extended
toward the brain.
Hyperostosis. — Excessive and irregular development
of bones of the skull may cause distortion, displacement
and great asymmetry of the orbits.
Imperfect development of the orbit may, but
does not always, occur after early enucleation of the eye.
DISEASE OF ADJOINING SINUSES.
Allusion has been made to the share of diseases of the
nose or its accessory sinuses in causing optic neuritis,
narrowing of the field, or loss of vision, impairment of
accommodation, vitreous opacities, disease of the conjunc-
tiva, cornea, or uveal tract; and a more general summary
of the subject will be found on page 582. It is here
necessary to consider the direct extension of sinus diseases
into the orbit, and the symptoms and complications which
they cause.
Disease of the maxillary antrum, more common
than was formerly recognized, may arise from disease of
the upper teeth, coryza, or in connection with influenza
DISEASES OF THE FRONTAL SINUS. 477
or other infectious diseases. The pain it causes must not
be ascribed to glaucoma, iritis, or eye-strain. It may be
attended by edema of the lids, conjunctival swelling, or
retinal hyperemia. Antral abscess extending into the
orbit causes all the symptoms of orbital inflammation,
with displacement of the eyeball upward, paresis of the
inferior rectus or inferior oblique, and the appearance of
a tumor in the lower part of the orbit. The recognition
of the cause of the orbital disease may depend on recogni-
tion, by trausillumination, of filling of the autrum, or by
clinical history of previous antral disease. Malignant
growths, starting in the antrum, may cause much the
same train of symptoms. Treatment of the antral disease
is the primary indication.
Disease of the Frontal Sinus. — Temporary closure
of the passage between the frontal sinus and the anterior
cells of the ethmoid is followed by a sense of fulness in
the frontal region, or frontal headache, which may become
extremely severe, and tenderness over the pulley of the
superior oblique. Recurring attacks of headache from
this cause may be wrongly ascribed to eye-strain. Where
the closure is due to swelling of the mucous membrane, it
may be cut short by passing a probe into the sinus, or by
the application of adrenalin solution to the upper part of
the nose. Chronic or permanent closure of the exit from
the frontal sinus is followed by the accumulation of
mucus, causing mucocele ; or pus and abscess or empyema
of the sinus. The accumulation causes a loss of the red
glow over the sinus usually obtained by transillumination
with a small electric lamp placed beneath the brow. It
is customary to compare the appearances obtained on the
two sides ; but frequently the disease affects both sides,
or one side of the sinus may be very small or absent.
An X-ray examination may be a valuable supplement to
the transillumination test. The pain or headache is
usually continuous, but subject to severe exacerbations
and made worse by stooping or straining. There is com-
monly some tenderness over the sinus. Abnormal dis-
charge into the nose is usually absent. Often the dis-
478 DISEASES OF ADJOINING SINUSES.
ease is unrecognized until distension of the sinus causes
bulging downward of the roof of the orbit, or a fistulous
opening through the bone leads to orbital inflammation
and abscesses.
Displacement of the eyeball is apt to be downward and
outward, but swelling in the orbit may also cause for-
ward displacement, Even at this stage, the passage of a
probe through the fistulous opening into the sinus may be
necessary to differentiate the condition from orbital
periostitis. Where the disease has not extended into the
orbit, intra-nasal treatment may be sufficient. But where
the orbit has been invaded, it becomes necessary to pro-
duce obliteration of the frontal sinus by one of the
operations described in works on the diseases of the
nose.
Ethmoidal Disease. — Mucocele and empyema of
the ethmoidal cells are quite liable to cause destruction
of the orbital plate ; and tumor, or suppurative inflamma-
tion within the orbit. The displacement of the eyeball is
commonly outward and forward. The condition may
resemble severe lacrimal disease. The probing of a
fistula may be necessary to establish a diagnosis. It is
probable that, without any such extension into the orbit,
ethmoidal disease is associated with some cases of disease
of the uveal tract and vitreous opacity.
When the ethmoidal disease has not broken through
the orbital wall, free drainage through the nose and
appropriate intranasal treatment may effect a cure. When,
however, an abscess or fistula in the orbit communicates
with the ethmoidal cells, a free opening should be made
through the orbital tissues and the ethmoidal cells into
the nose, a drainage tube inserted, and the cavities kept
thoroughly cleansed.
Sphenbidal disease is not known to extend into the
orbit except through the ethmoid. It may, however,
cause thrombosis of the orbital vessels, as well as optic
neuritis and optic atrophy, through the close relation of
the sinus to the cavernous sinus, orbital veins, and optic
nerve.
MECHANICAL INJURIES. 479
CHAPTER XVII.
MECHANICAL INJURIES OF THE EYE AND ITS
APPENDAGES.
CONTUSIONS.
THE lids with their loose cellular tissue permit free
extravasation, and free diffusion of the blood which is
extravasated.
Hence bruise of the lids is likely to be followed by
very noticeable ecchymosis and much swelling. The
swelling comes and goes rapidly. The discoloration takes
one or more weeks to disappear. The lids also become
discolored from hemorrhage attending injuries to the
bones of the orbit, or the base of the skull. With such
injuries, the discoloration appears many hours or days
after the injury, and then not at the point of impact but
at the part of the lids just within the margin of the orbit.
In bruise of the lids extravasation is checked by the
immediate application of pressure. The traditional beef-
steak, with its astringent albuminous juices, offers an
excellent method. Equally efficacious is the prompt
application of cold, as by an ice-compress. The benefit
of cold ceases with the period of extravasation. After
that, pressure, and later occasional hot fomentations, and
massage, are indicated.
Heavy contusions about the head are liable to cause
fracture of the bones of the orbit, with important
effects on the eye and its appendages. Fracture of bones
enclosing air spaces connected with the respiratory tract
may admit air to the cellular tissue, causing emphysema
(see page 459). Blows on the brow or the frontal and malar
eminences are transmitted to the sphenoid, where their
force may cause fracture involving the optic foramen, and
immediate blindness, from laceration or compression of
the optic nerve. At first the ophthalmoscopic appearances
may be normal, but in a few weeks white atrophy of the
optic nerve appears ; and from the first the pupil responds
480 FRACTURE OF BONES OF THE ORBIT.
imperfectly or not at all to light thrown into the affected
eye.
Paralysis of other cranial nerves may follow fractures
of the base of the skull, either at once from laceration or
hemorrhage, or gradually after several days from pressure
by exudate or callus. The abducens is by far the most
frequently affected, the paralysis being often bilateral.
Dislocation of the eyeball may be produced by
certain contusions, as by the horn of a cow. The globe
has thus been pushed out so that the lids fell behind it,
or has been thrust into the nasal cavity or maxillary
antrum. Fracture of the walls of the orbit thrusting them
outward, or atrophy of orbital tissue following injury,
have caused enophthalmos (see page 471). Fracture of the
walls of the orbit, thrusting them in, emphysema, hemor-
rhage, inflammatory exudate, or the palsies of the ocular
muscles cause exophthalmos. Traumatic pulsating exoph-
thalmos is elsewhere described (page 472). Traumatic dis-
location of the lacrimal gland into the lid has occurred.
Rupture of the eyeball is caused by blows like that
of the fist. It is commonly located a little back of the
upper inner part of the corneal margin, and parallel with it.
Often the crystalline lens, and sometimes also the iris, is
dislocated through the rupture, beneath the conjunctiva.
The line of rupture appears somewhat irregular, and dark
with incarcerated uveal pigment. The lens is at first
yellowish, becoming whiter and shrunken with the lapse
of time. The iris if not torn from its attachment falls
back from the cornea, especially in the direction of the
rupture, where it may be folded under so as to be entirely
concealed. The softness of the eyeball immediately after
injury will reveal the existence of a rupture, if located so
far back that it cannot be seen.
After recent rupture, the prolapsed lens or iris should
be removed from beneath the conjunctiva, and the edges
of the rupture drawn together with fine sutures. Usually
the injuries to the interior of the eye are so great as to
make the eye useless ; but a few cases recover with use-
ful sight by the aid of lenses.
MECHANICAL INJURIES. 481
Contusion of the eyeball not powerful enough to
cause rupture of the sclera occurs from a blow with a
small stone, a marble, the cork of a champagne bottle, or
the knot on the end of a whip-lash. It may cause con-
junctival ecchymosis, rarely a small superficial slough
and ulcer of the cornea, and often serious damage to struc-
tures within the sclerocorneal coat.
Rupture of the iris from contusion of the eyeball is
not rare. It may occur at the ciliary border, iridodlalysis,
causing a false pupil behind the margin of the cornea,
and a flattening of the side of the normal pupil toward it,
as shown in Fig. 143. Radiating ruptures of the iris also
occur. They may appear either as nicks in the margin
of the pupil, rupture of the sphincter, or fissures in the
substance of the iris. These are shown in Fig. 144. Such
FIG. 143.— Iridodialysis, tearing of iris from its ciliary attachment, making
a false pupil, through which is seen the lens-margin, and causing flattening
of the true pupil. Ophthalmoscopic illumination.
FIG. 144.— Multiple ruptures of the iris. Tears in the sphincter, and separa-
tion of the radiating iris-fibers.
lesions are attended with hemorrhage into the anterior
chamber, hyphemia (page 408) which may for a time conceal
them or may call attention to a rupture so small as other-
wise to be overlooked. Such hemorrhage is commonly
entirely absorbed in two or three days, but it may recur.
Paralysis of the iris-sphincter (traumatic irido-
plegia) without rupture may occur from stretching. The
pupil is found partly dilated and sluggish. It usually
regains its power in a few days or weeks. Permanent
dilatation is more apt to depend on slight rupture.
Traumatic cycloplegia, paralysis of accommoda-
tion from injury to the ciliary body, may also occur, caus-
ing imperfect vision from inability to focus near objects.
31
482 CONTUSIONS OF THE EYEBALL.
A temporary astigmatism may arise from injury to the
same part.
There may also be hemorrhage into the vitreous,
causing complete loss of sight until it is removed by
absorption.
The treatment for such injuries by contusion, is at
first complete rest of the eye, under a mydriatic, with the
application of cold if there are signs of violent reaction.
After all symptoms of inflammation have subsided, it
may be well to try the effect of a myotic if the pupil
remains dilated. When iridodialysis causes diplopia or
annoying diffusion, an incision may be made in the ex-
treme periphery of the cornea opposite the center of the
separation, and *he edge of the iris drawn into it and
incarcerated or fastened with a stitch ; or the detached
portion of the iris may be removed by iridectomy. Such
injuries to the iris often permanently impair vision.
Injuries of the lens by contusion of the globe in-
clude traumatic cataract and dislocation of the lens.
The former is caused by rupture of the lens-capsule and
differs little from that caused by penetrating wounds.
Dislocation of the lens (see page 424) may be into the ante-
rior chamber (Fig. 145). More commonly it is backward,
FIG. 145.— Dislocation of the clear lens into the anterior chamber. Iris and
pupil seen through the lens. Pericorneal hyperemia.
and still more frequently it is only partial, the lens tilting
back at some part of the circumference, causing myopia
and astigmatism by its increased curvature and oblique
position. These results may be permanent or there may
be considerable recovery. Such injuries should be treated
by the early application of cold to diminish reaction,
rest, and usually the placing of the eye under a mydriatic.
MECHANICAL INJURIES. 483
Later a myotic may be beneficial, and the measures indi-
cated on page 425 become appropriate.
Traumatic Edema of the Retina (Commotio Re-
tinae}.— Bruise of the eyeball is sometimes followed by
temporary impairment of sight without any external evi-
dence of injury. But the ophthalmoscope shows in the
first few hours a diffuse gray haziness or more dense
opacity of the retina at the posterior pole of the eye,
probably due to edema. This haziness soon begins to
i
FIG. 146.— Traumatic edema of retina and choroid, four hours after contusion
of the right eye. The dark spot is the center of the macula.
diminish and passes off entirely in from two to four days.
It is often associated with slight lesions of the choroid,
which remain visible longer. After disappearance of the
retinal opacity, the vision is soon restored to normal.
Rest of the eyes, with guarding against excessive light is
all the treatment required.
Injuries of the Choroid. — With the changes of the
retina above described, there often occur small patches
of light, yellowish, swollen choroid, which may be
484
INJURIES OF THE CHOROID.
arranged in something of an arc or crescent concentric
with the optic disk. These, if not attended with hemor-
rhage, fade gradually away after a few days, the fnndus
becoming quite normal in appearance. But if the injury
has been more severe, the patches may run together form-
ing one or more light crescents, or these may for a time
be concealed by hemorrhage into the vitreous. A few
weeks later, when the hemorrhage has been absorbed, the
FIG. 147.— Rupture of the choroid, right eye, from contusion by a small
stone. The " rupture " lies between the disk and the macula.
crescent is found to be a choroidal atrophy with massing
of pigment along its borders. Often there are also in-
complete choroidal atrophies in other parts of the fundus.
This is the appearance known as rupture of the choroid
and illustrated in Fig. 147. The retinal vessels are seen
to cross the atrophic area uninjured. The lesion is prob-
ably an atrophy following injury and partial rupture of
the tissue of the choroid. Its striking curved form,
MECHANICAL INJVRIES. 485
usually roughly concentric with the optic disk, may be
due to a sharp bending of the coats of the eye occurring
along this line, when the globe is forced back against the
support given by the optic nerve. In severe, injuries,
effused blood may pass behind the choroid detaching it
from the sclera.
Treatment is similar to that of other contusion-lesions
within the globe — rest under a mydriatic. After the
slight lesions, recovery may be complete. But " rupture"
is usually attended with marked permanent impairment
of vision.
In rare cases optic neutritis or atrophy may be due to
force transmitted to the nerve from bruise of the eyeball
or other contents of the orbit.
WOUNDS WITHOUT LODGEMENT OF FOREIGN BODIES.
Although it is convenient to consider apart wounds
complicated by the lodgement of a foreign body, it is best
to regard every case of traumatism as possibly compli-
cated in this way, until investigation reveals the contrary.
The question of probable infection must also be con-
sidered in every case, and the effort made to render the
wound aseptic. In doing this it must be remembered
that hemorrhage is a guard against sepsis, and should not
be checked too promptly, nor should effused blood be too
industriously diluted and washed away by watery solu-
tions.
Wounds of the lids, on account of the vascularity
of the parts, unite early. But because of the looseness
of the tissues involved, the lips of the wound are very
liable to be displaced ; and if they unite thus, a permanent
deformity is caused. On this account it is extremely
important that the parts should be at once brought into
proper apposition, and permanently fixed by a sufficient
number of well-placed sutures. Any delay about doing
this is especially harmful, increasing the amount of scar-
tissue, where for cosmetic reasons, as well as the future
flexibility and usefulness of the part, it is especially
486 WOUNDS OF THE LIDS.
important to reduce the scar-tissue to a minimum.
When there is absolute loss of tissue, it is better to re-
place this by drawing in neighboring tissue by some
plastic operation than to trust to its replacement by
granulation-tissue.
The resulting deformity is least when the wound lies
parallel to the fibers of the orbicularis muscle. It is
likely to be greatest and most difficult to prevent when
the wound extends through the free edge of the lid. In
some of these cases a fine straight needle and harelip-
suture may give the best result. Care should be taken
to secure cleanliness of the surfaces brought together, and
inflammatory swelling must be kept down by the con-
tinous application of cold. The stitches should be care-
fully placed, including the depth of the tissues. They
may be inspected each day, and any that show evidences
of stitch-hole abscesses, removed early. But some must
remain until the swelling subsides and union is likely to
be firm. If the stitches are withdrawn early, the parts
must be supported and protected by properly placed strips
of adhesive plaster. The same dressings are to be em-
ployed as after operations on the lids (see Chapter XIX).
Wounds in certain regions require special care. Thus
the division of a canaliculus generally makes it necessary
to slit both portions to prevent obstruction to the flow of
tears. A wound of the upper lid may divide the tendon
of the elevator muscle, in which case the divided ends
must be searched for, and united to prevent permanent
ptosis. Deformity of the lids caused by old scars can
sometimes be lessened by prolonged massage ; but may
require some of the most delicate and difficult of plastic
operations. Swelling of the lids should never prevent
careful search for accompanying lesions of the eyeball.
Penetrating wounds of the orbit are usually deep
in comparison with their extent on the surface. They
are, therefore, especially liable to hide foreign bodies, dif-
ficult to thoroughly cleanse, and uncertain as to the
structures involved. They may even be entirely con-
cealed, or easily overlooked on account of the swelling of
MECHANICAL INJURIES. 487
superficial structures. Injury of the optic nerve will
cause instant blindness. Injury to a muscle causes
impairment of function that may only be discovered
later. Hemorrhage, or emphysema produces exophthal mos,
which, from the latter cause, is reducible by pressure.
In the treatment of such wounds, the removal of any
foreign body, cold to keep down swelling, asepsis, and
drainage are the important points. Shortly after injury,
the wound should be washed out with warm boric acid
or salt solution. Later, hydrogen dioxid should be em-
ployed. If there is tendency to the formation of a sinus,
a drainage-tube should be introduced, or the wound
packed with iodoform gauze.
Wounds of the conjunctiva only usually require
cleansing, the replacing of any flap in normal position,
and closing of the eye for one or two days until union
can occur. Very extensive division and separation of the
membrane may require sutures. They should be fine and
removed by the third or fourth day.
Wounds of the Cornea. — Even slight abrasions of
the cornea, such as are often made by the finger-nail of
an infant, may cause extreme pain, with photophobia and
inability to use the eyes. The cornea is particularly
liable to infection ; so that all corneal wounds should be
closely watched until the surface is again covered with
epithelium. Even after this, an erosion may recur with-
out evident cause. Corneal injuries are particularly dan-
gerous in the presence of lacrimal obstruction.
On account of the rigidity of the cornea, there is very
little tendency to displacement of the parts ; so that even
extensive irregular wounds very rarely require suture.
Deep wounds always leave some permanent impairment
of transparency, although this may be slight, and if not
in front of the pupil, of no importance. When the wound
extends into the anterior chamber, the escape of aqueous
humor causes the loss of the normal tension of the globe, and
abolition of the anterior chamber. Wounds of the cornea
involving deeper structures are chiefly of importance in
that connection.
488 WOUNDS OF THE CORNEA.
The treatment must include careful cleansing, repeated
daily, the instillation of a mydriatic, protection of the
eye by a light dressing, to prevent the entrance of par-
ticles of dust which tend to lodge in the wound ; and if
this is of some length and extends through the cornea, com-
plete rest of the eyes, and even rest in bed, until union
has occurred. Cold applications should be used with
caution.
Wounds of the sclera, if they do not perforate it,
require simply cleansing, and heal quickly. If they ex-
tend through the whole thickness, they cause diminished
tension of the eyeball, and danger of infection of the
vitreous. All structures prolapsing into the wound should
be excised. The wound must be carefully cleansed, and
if extensive, closed with one or more fine sutures. Cold
may be used for the first day or two, to keep down reac-
tion ; and the eye should be kept at rest under a mydriatic
until repair is well started. Very extensive wounds of
the sclera may still allow recovery of the eye, even with
useful vision. When, however, from the general disor-
ganization of the eye, or the commencement of irido-
cyclitis, it becomes certain that only a sightless and
disorganized globe can remain, it will greatly shorten the
period of disability, as well as remove the danger of
sympathetic ophthalmitis, to promptly enucleate the in-
jured organ.
Wounds into the ciliary body are regarded as
especially dangerous. The prolapse of the ciliary body
into the wound is likely to interfere with drainage,
and consequent swelling of the lens may increase the
obstruction, and infection is especially liable to occur.
Especial care must, therefore, be taken to remove all
prolapsed or injured tissue, even though this necessitates
enlarging the original wound.
Wounds Involving the Iris. — That a penetrating
wound involves the iris may be suspected from the pres-
ence of blood in the anterior chamber ; or recognized by
distortion of the pupil, or the existence of a second opening
in the iris. Prolapse of the iris into a corneal wound
MECHANICAL INJURIES. 489
appears as a rounded dark brown tumor, at the site of the
wound, while the pupil is found distorted, and the iris-
tissue dragged in the direction of the prolapse. The pro-
truding iris is at first readily distensible by the escaping
aqueous, and may appear to include more of the iris than
it really does, and may vary in size from day to day. It
soon becomes covered with a layer of gray translucent
lymph, and then slowly flattens down to an adherent
leucoma, unless it be quite extensive or the surrounding
cornea softens, in which case more iris may be drawn in,
and anterior staphyloma develop.
Treatment. — Simple incision of the iris, or clean
removal of a part of it, is generally not followed by
excessive reaction, or prolonged healing. When, however,
the iris prolapses into a corneal or scleral wound the case
is more serious. In a few cases of prolapse into small
corneal wounds, the iris may be pushed back into position
and the prolapse not recur. Cases of prolapse near the
periphery may be left to flatten down without further
trouble. But in all cases of large prolapse near the
center of the cornea, or of probable infection of the pro-
truding iris, that are seen within the first day or two, the
protruding portion should be cut off, and the stump freed
as far as possible from its adhesions to the cornea. From
about the third to the tenth day it may be best not to
excise a prolapse of the iris, because of increased risk of
general infection of the eye. After the tenth day the
excision of the prolapse should be done if it seems to be
extending. Prolapse of the iris greatly retards the com-
plete healing of the wound, a large prolapse taking six or
eight weeks to flatten down.
Wounds of the iris are to be treated with rest and
mydriatics until the eye is free from redness and irrita-
bility. At first cold may be used to lessen the reaction,
if it does not injuriously influence the cornea. The eye
should be kept closed with a light dressing (see Chapter
XIX) until the corneal wound is well united, or the
prolapse is flattening down.
Wounds of the lens cause swelling and opacity
490 TRAUMATIC CATARACT.
which generally goes on to traumatic cataract, and in
young persons may be followed by complete absorption
of the lens. The opacity may be noticed with the oph-
thalmoscope, or by oblique illumination, immediately after
the injury. It begins at the wound, and extends with a
rapidity proportioned to the size of the opening in the
lens-capsule. If this is large the whole lens may become
hazy in a few hours. (See Fig. 148.) If the progress is
FIG. 148. — Traumatic c§taract, commencing, after wound of lens, with small
prolapse of iris.
slower the opacity may assume a somewhat stellate form,
closely resembling posterior polar cataract. (See Fig. 130.)
When the wound in the capsule is quite small it may en-
tirely close, and the opacity disappear, or remain perma-
nently confined to the immediate seat of injury. Some-
times the haziness of the lens becomes general immediately
after the injury, then in a few weeks clears up to a great
extent, but several months later the lens slowly becomes
entirely opaque.
When the opening in the capsule is large, the swelling
of the lens pushes out fragments of the cortex or even the
whole nucleus. These lie in the angle of the anterior
chamber until dissolved and absorbed. They usually
cause pericorneal redness, pain, photophobia, and may
even occasion iridocyclitis and loss of the eye.
Treatment. — The eye should immediately be placed
under atropin, with rest and protection from excess of
light. If the wound is minute, this gives the best chance
of healing without causing general opacity ; and the com-
plete inaction of the ciliary muscle must be thus main-
tained for many weeks. If the swelling of the lens is
great, and the eye shows signs of irritation, the lens, or
at least the nucleus and greater part of the cortex, should
MECHANICAL INJURIES. 491
be extracted. If the patient is young and the lens-changes
cause no serious disturbance, they may be allowed to pro-
ceed without interference until absorption is complete ;
or if it cease, one or more needle-operations may be done
to renew the process until the pupil is clear. If the
wound is through the ciliary region it will be best to
enlarge it and remove the lens with other injured tissues
without delay. After removal of the crystalline, a cor-
recting lens will be required for distant vision ; but
usually it will be impracticable to employ the eye along
with the other if it has good vision.
Wounds involving the vitreous are of importance
chiefly on account of their liability to infection, which
will be considered in connection with the lodgement of
foreign bodies.
FOREIGN BODIES IN THE EYE AND ORBIT.
The possible lodgement of a foreign body should be
considered in connection with every penetrating wound
of the eye or its related structures. Their removal is
necessary to recovery, and their presence is liable to be
quite overlooked. They are searched for in the same
general way as foreign bodies imbedded in other parts of
the body.
For pieces of metal and glass, that are not too minute,
the Rontgen or x-rays afford very valuable assistance.
The importance of locating a foreign body exactly has led
to the taking of radiographs, from different directions ;
and the use of a metal indicator (method of Sweet) placed
at a known position in front of the eye, with the radio-
graph of which that of the foreign body can be accurately
compared. To get the best results, a current of high ten-
sion must be used allowing a short exposure ; and the
patient should be placed in a comfortable attitude, (best
lying down), to lessen the blurring due to slight changes
of position. The sensitive plate is bound to the temple
next the injured eye, and the tube placed on the opposite
side of the head and rather in front. To locate foreign
492 USE OF ROXTGEN RAYS..
bodies in the orbit, bits of lead may be fastened to the
skin at known points on the orbital margin to give points
for comparison.
I/ids and Orbit. — The swelling of the lids after in-
jury readily conceals any foreign body lodged in a wound
made in or through them ; hence in every case, the
depth of the wound should be carefully examined, enlarg-
ing it if necessary to admit the little finger for the pur-
pose. Very large foreign bodies have been extracted
from the orbit, or from the maxillary antrum, nose, or
brain-cavity, into which they had passed through the orbit,
when the history of the case, or the previous examina-
tions by other surgeons, had given no indication of their
presence. When found a foreign body must be removed.
Especial care should be taken to secure very free drainage,
if there is any suspicion of penetration of the cranial
cavity.
Powder-grains are liable to be lodged by accidental
explosions in the lids, conjunctiva, cornea, or sclera.
The potassium nitrate and sulphur of the grain are
quickly removed, causing a temporary inflammation ;
while the fine particles of charcoal become gradually
diffused through the neighboring tissues, causing a perma-
nent bluish stain. Removal of the grains should be
effected as quickly as possible. The more superficial
may be removed by thorough scrubbing. The deeper
grains should be touched with the galvano-cautery, or
with nitric acid, causing a slough in which the particles
of carbon are imbedded. These procedures may be car-
ried out. under local infiltration-anesthesia if the grains
are few, but if the grains are numerous, they require
anesthesia by chloroform.
Foreign Bodies in the Conjunctiva. — These have
direct access only to the part of the conjunctiva exposed be-
tween the lids on either side of the cornea ; but they are
liable to be carried by the rubbing of the lids on the eye-
ball into other portions of the conjunctival sac. Most fre-
quently small particles will be found to rest on the surface
of the upper lid, about the middle of the upper border
MECHANICAL INJURIES. 493
of the tarsal cartilage, as illustrated in Fig. 149. But
they may become lodged in other portions, especially in
the retrotarsal folds ; and if retained many hours, they
FIG. 149.— Foreign body lodged on conjunctiva of upper lid. Lid everted to
snow the usual point of lodgement.
become imbedded in the swelling caused by their pres-
ence, and even large masses may remain concealed for
months. The heads of grass, and grain, and hairs of
caterpillars are likely to become imbedded in the swell-
ing of granulations they cause, and thus remain unde-
tected. (See Ophthalmia Nodosa, page 243.)
Foreign bodies are to be searched for ; first by careful
inspection of the exposed portion of the ocular conjunc-
tiva ; then by the eversion of the upper lid (see page 58) ;
then by retraction of the lower lid with the eyeball turned
strongly upward ; and then the lifting of the upper lid
from the globe, while it is turned strongly downward.
Points of inflammation and swelling of the membrane
are to be very carefully exposed. When found the for-
eign body is to be promptly removed. Usually it can be
wiped away with a pledget of cotton, otherwise it may
be seized by fine forceps. Particles of quicklime, or
of metal that has entered in a molten state, may require
snipping loose with the scissors.
Foreign bodies in the cornea cause much pain and
discomfort when they project sufficiently to scratch the
upper lid with every, act of winking. But if entirely
imbedded, they may be unnoticed until after one or more
days' attention is drawn to the eye on account of the re-
sulting inflammation. Then there are found pericorneal
redness, photophobia, excessive lacrimation, a contracted
pupil, and often reddening of the optic disk. If left
alone, suppuration goes on around the foreign body, with
494 FOREIGN BODIES IN THE CORNEA.
all the dangers of a suppurating ulcer of the cornea,
until the foreign body is loosened and wiped away by
the lids
In rare cases, suppuration does not occur, but the cor-
neal epithelium proliferates around it until the foreign
body is imbedded in white epithelial masses, which lie in a
depression of the corneal surface. It may thus be retained
for weeks, months, or even years. The resulting lesion is a
white or gray spot, which may or may not have vessels
running to it from the limbus. It is illustrated in Fig.
150. Particles of powdered charcoal, the residue of a
powder-grain, and a few other aseptic substances, may
FIG. 150.— Appearances caused by foreign body retained six weeks in the
cornea.
remain in the cornea indefinitely without causing irrita-
tion. Other substances act as irritants of a specific
character, as the fragments of oyster shells, which cause
" oyster-shuckers' keratitis."
Diagnosis. — Haziness of the cornea, or greater con-
gestion of the nearest portion of the pericorneal zone,
may point out the location of a foreign body ; or this may
be revealed by irregularity of the corneal surface, which
can be detected by placing the cornea so that the surgeon
can see in it the reflection of a large window, and wiping
away the tears and mucus with a swab of absorbent cot-
ton ; or by a drop of fluorescin solution, which will color
any point where the corneal epithelium has been lost.
But a foreign body may be deeply imbedded, and may
produce the most serious effects, although so small as to
be scarcely visible to the unaided eye. The cornea must
therefore be searched with the ophthalmoscope, using
the strongest convex lens with which it is furnished, to
MECHANICAL INJURIES. 495
discover anything lodged in front of the pupil, and with a
good magnifier under oblique illumination.
Foreign bodies in the cornea must be distinguished
from small opacities in the deeper media (see page 81),
exudates in the cornea, or even specks of pigmentation on
the iris.
Treatment. — The foreign body should be at once re-
moved (see Chapter XIX) with the damaged and soft-
ened tissue around it. This includes the removal of the
ring of brown staining which quickly forms around any
foreign body containing iron, and which if left will
separate subsequently after prolonging the irritation (see
also page 499). Any remaining ulcer is to be treated
as directed on pages 277 and 282.
Foreign bodies in the sclera may be quite con-
cealed by the swelling of the conjunctiva. If left there,
they may remain for many years without causing irrita-
tion, or may ultimately be thrown off.
Anterior Chamber and Iris. — A wound through
the cornea or limbus, with the diminished ocular tension,
reveals that the wounding substance has penetrated the
globe. Usually it goes deeper, but sometimes it stops in
the anterior chamber or iris, and a careful search should
be made for it there. Hemorrhage into the anterior
chamber may conceal it for a time ; but usually careful
search by oblique illumination will disclose it, for the
most minute foreign bodies have not sufficient force to
pass through the cornea.
Treatment. — If imbedded in the iris, the foreign
body may sometimes be picked out with the magnet (if
steel), or with fine forceps introduced through an incision
in the nearest part of the periphery of the cornea. But
usually it is much safer, as well as easier, to do an iri-
dectomy, removing the injured portion of the iris with
the foreign body in it. When the foregn body lies loose
in the anterior chamber, it should be extracted through
an incision in the lower part of the limbus. The subse-
quent treatment is, cold to reduce reaction, rest, the use
of a strong mydriatic, and other treatment for iritis. All
496 FOREIGN BODY IN THE IRIS.
foreign bodies in the anterior chamber are dangerous ;
even an eyelash or bit of epithelium carried in through
a perforating wound of the cornea, becomes the starting
point of a cyst (see page 332).
I/ens. — In the lens a foreign body necessarily causes
cataract, which will soon conceal it. It is therefore im-
portant in all cases of foreign body in the eye to carefully
examine the lens with the ophthalmoscope, and oblique
illumination and a good magnifier, as soon after the
injury as possible. If the opacity has already gone so
far as to make the presence of the foreign body uncertain,
the Rontgen rays, or the subsequent presence or absence
of inflammation of the uveal tract, must be relied on for
a diagnosis.
A foreign body in the lens does not usually cause in-
fection of the eye, or severe inflammatory symptoms,
unless there is great swelling and rapid disintegration of
the lens. With the foreign body in the lens it is there-
fore advisable to wait until the traumatic cataract has
matured, or so far advanced as to make its removal
necessary, and then the lens should be extracted through
a rather large incision, with an upward iridectomy, if
this is necessary to give the swollen lens free exit. The
foreign body will nearly always be extruded with the lens-
substance ; if it is not it must be removed with a mag-
net, scoop or forceps.
Vitreous, Retina, and Choroid. — A foreign body
entering the vitreous and remaining in it, or penetrating
the coats of the back of the eye, usually causes infection,
and loss of the eye through purulent or chronic plastic
inflammation ; and, so long as it remains, it constitutes
an especial menace to the other eye, through sympathetic
ophthalmitis. The foreign body may be small, the sight
at first unimpaired, less pain may be felt than from a
slight abrasion of the cornea, and yet the eye may be
doomed to immediate destruction.
If the foreign body be small the reaction may be slight,
severe inflammation not setting in until the consequences
of infection extend from the wound to other structures,
MECHANICAL INJURIES. 497
but the ultimate loss of the eye is none the less certain.
If the foreign body be large, its entrance causes so much
hemorrhage and general disturbance that sight is at once
lost, and the patient may show decided symptoms of
shock. Great edema of the conjunctiva and lids may
quickly occur, so that in a few hours the eye shows clear
evidence of severe injury, and before these symptoms
subside the suppurative or chronic plastic inflammation
is fairly started. Some foreign bodies, as metallic copper
and its alloys, cause inflammation by their chemical
properties even when aseptic.
Diagnosis. — After injury, the eye should be thoroughly
examined at the earliest possible moment. It may then
be easy to determine the presence or location of a
foreign body which a few hours later would be quite
concealed by increased opacity of the lens or diffusion
of hemorrhage. The pupil should be dilated and a care-
ful ophthalmoscopic examination made of every part of
the interior of the eye. Metallic particles are generally
detected by their glitter. Air-bubbles in the vitreous
which appear as spheres with a dark outline, although
they tend to rise to the upper part, may indicate the
direction taken by the foreign body ; or its track may be
marked by shreds of blood-clot. A localized hemorrhage
may be found to conceal it ; or a wound of exit may
be discovered.
If the foreign body cannot be seen, careful inquiry
must be made as to the probable nature of the body by
which the wound was inflicted, its size, and the direction
of impact. If it be a piece broken as from the edge of
a chisel, the size and shape can be ascertained by in-
spection of the tool. If a fragment is believed to have
struck the eye, and not to have entered, only the finding
of the fragment can be regarded as proving this. Patients
are likely to assert positively that nothing has remained
in the eye, because the familiar sensation of a foreign
body on the surface is lacking, or because they hope that
the injury is not so serious. Sometimes there is even a
clear, but incorrect, history of the wounding body having
32
498 FOREIGN BODY IN THE VITREOUS.
dropped out after injury. If, with a corneal wound,
there is also penetration of the iris or lens, it may be con-
fidently assumed that the wounding body has passed in ;
and we may presume it has remained, unless it be some-
thing like a piece of wire, which has been pulled out
afterward. The discovery of localized hemorrhages in
the fundus quite unconnected with the wound of entrance
is a strong indication of the presence of a foreign body.
When nothing can be seen with the ophthalmoscope,
the field of vision should be taken with a candle in the
dark-room ; and a marked scotoma, or other defect in the
visual field may indicate the location of the foreign body.
Instantaneous blindness, produced by a small foreign
body, as a bird-shot, indicates that the optic nerve has
been struck either at the disk or behind the eyeball.
Ecchymosis of the lids appearing some time after the in-
jury, and most intense near the margin of the orbit, or
ecchymosis of the conjunctiva, appearing similarly in
the retrotarsal fold, is evidence of orbital hemorrhage,
which, if not from the wound of entrance, proves that
the foreign body has not lodged in the eyeball, but has
passed on into the orbit. If a foreign body, as a bird-
shot, has entered the eye through the posterior. segment,
the softening of the globe, and hemorrhage in the
vitreous announce the accident.
The Rontgen rays should be appealed to in all doubt-
ful cases. But some foreign bodies cast no appreciable
shadow from them; and even metallic particles if smaller
than 1 mm. in two dimensions, are likely to give no
evidence of their presence.
Treatment and Prognosis. — The earliest possible re-
moval of the foreign body is the first thing to be consid-
ered in the mass of cases. It should usually be done at
any cost, even to the removal of the eye. Particles of
iron may often be removed by the magnet (see Chapter
XIX). The certainty of the removal is proportionate to
the strength of the magnet and the size of the bit of
steel. Other foreign bodies, not influenced by the magnet,
must be removed, if possible, by forceps or a scoop. For
MECHANICAL INJURIES. 499
this purpose it is the surgeon's duty to open the eyeball
whenever the location of the foreign body can be known
with strong probability.
The second point is to remove all badly damaged and
probably infected tissue. On this account, the wound of
entrance should be enlarged, or the new incision made
free ; and all tissue in which the foreign body is entangled
should be removed with it. After this, the treatment is
to be that appropriate to wounds of the parts, careful
cleansing, cold to subdue reaction, rest of the eye, and
rest in bed until reaction begins to subside.
A few foreign bodies pass through the vitreous into the
retina, choroid, or sclera, without causing infection or seri-
ous inflammation. These have usually entered through
the cornea, and iris, or lens, or have passed through
the lids. They are usually very small. When such a
foreign body is firmly imbedded and has remained quite
innocuous for several days or weeks, it is proper to let it
be and await developments. But such cases are so rare,
that the possibility of a benign course ought not to
influence the treatment of recent cases.
Even after the successful extraction of a foreign body
the safety of the eye is not assured. In the majority of
cases, useful vision will be lost, and the injured eye may
have to be sacrificed for the safety of the other. Even
when the eye seems to do well for a time, it may become
the seat of a slow uveitis that after weeks or months will
destroy it. The prospect of a useful eye is best after
early removal of a small foreign body which has entered
through the iris and lens, and when the tissue in which
it lies has been removed with it.
500 KEST.
CHAPTER XVIII.
REMEDIES AND THEIR APPLICATIONS.
ROENTGEN RAYS.
Roentgen Rays. — Beside the harm the X-rays do
to other parts of the body, experiment has shown they
can do great damage to the eye. They should be applied
by one who has a fair knowledge of their effects and
experience in their application under skilled supervision.
But, if used with caution, experience shows that the
X-ray may be effectively employed for diseases of the eye
without any necessary risk of serious unfavorable effects.
Care must be exercised to avoid (a) too long exposures ;
(6) too many exposures before the patient's susceptibility
has been thoroughly tested (several weeks) ; (c) unneces-
sary exposure of healthy parts. To meet the last require-
ment, a shielded tube, a mask rendered impervious by tin-
foil or lead paint, or a plate of glass or metal with an
opening just large enough to expose the part to be treated,
may be employed.
REST.
Rest of the eyes may be made absolute by the use
of a cycloplegic and the complete exclusion of light ; or
by darkness alone, if the accommodation has been lost by
age. Commonly only relative rest is required. Under
the ordinary bandage light reaches the retina and stimu-
lates it to functional activity. Yet, with both eyes ban-
daged there is very little incitement to exertion of the
ocular muscles, and tinder cycloplegics there is rest from
the effort of accommodation.
Suspension of the customary occupation may be all the
rest required in a given case. Even the looking at dis-
tant objects is a valuable rest for those habitually engaged
at close looking. Directions to rest the eyes should
REMEDIES AND THEIR APPLICATIONS. 501
specify how they are to be rested. Rest, by use of lenses
and prisms, is discussed in Chapters VII and VIII.
Exclusion of the light is indicated in active inflam-
mations of the retina and photophobias of retinal origin.
Absolute darkness is rarely advisable, and only for
short periods, on account of the general depression it
causes. The chief benefits of exclusion of light are
gained by moderate illumination and avoidance of con-
trast, by sudden increase of illumination, or looking at
bright lights with a dark background. Smoked glasses
should be worn only during exposure to the brightest light,
or when the eyes are first exposed to bright light, being
removed when the eyes become accustomed to it. Amber
yellow glass is beneficial by excluding most chemical rays.
General rest, through its powerful influence on the
circulation and the nervous system, is an important means
of combating acute inflammation. Rest in bed is the
most complete rest for those who find it not irksome, and
it includes rest from many stimuli that act on the nervous
system when the patient is up. It is most important, in
the early stages of an inflammation, or to restore an
exhausted patient to a general condition favorable to heal-
ing. When it becomes decidedly irksome, it is generally
no longer helpful, but may have an effect quite the oppo-
site of that sought. Even when the object of so-called
rest is simply to prevent displacement of parts, as of the
flap after cataract extraction, or a graft after a plastic
operation, it may, if too rigidly enforced, defeat the pur-
pose, by causing a nervous irritability in which the patient
will not be able to avoid the slight movements that are
harmful.
MASSAGE.
Massage of the eyelids, often combined with the
use of boric acid powder or ointment, is sometimes a
\7aluable aid in chronic conjunctivitis and trachoma. The
required movements are those of stroking or friction of
the lid upon the globe, with some kneading between the
forefingers or the thumb and finger. The stroking should
502 MASSAGE.
be from the lid-margins. The manipulations for increas-
ing the efficiency of conjunctiva! applications are given
on page 505.
For episcleritis, pannus, and glaucoma, pressure is to be
made upon the eyeball through the closed lids. The
direction of the movements should be radial, from over
the center of the cornea toward the equator of the eyeball ;
and circular, around the center of the cornea as a center.
To reduce infiltrations, lessen the effects of cicatricial
contractions, and put the parts in the best condition for
plastic operations, pinching up of the skin of the lids, and
kneading or rolling it between the thumb and finger, is
an important procedure.
For cornea^ Opacities massage consists in stroking
the corneal surface in a radial or circular direction with
the back of a lens-spoon, spatula, or special instrument
made for the purpose, after the eye has been brought
under the influence of a local anesthetic. Massage of the
lens is considered under cataract operations.
Massage for glaucoma is performed by placing the
points of two or three fingers and the thumb so as to
press through the lids upon the anterior portion of the
sclera ; and by alternating the pressure and shifting their
position causing the dimpling of the different parts of the
eyeball.
APPLICATIONS OF HEAT AND COLD.
Dry heat is applied to relieve pain by covering the
eye with hot dry cloths, frequently changed, or sonic-
thing hot wrapped in flannel. The electric heater, in
which a proper current is passed through a flat coil of
light wire, is convenient ; but a coil of tubing through
which hot water circulates will serve. Hot air may be
obtained by forcing air through a heated tube. Dry air
may have a temperature of 100° to 150° C. A mixture
of air and steam may be used at a temperature of 40° to
50° C. Superheated air, secured by passing air through
a platinum tube coiled in the flame of a Paquelin burner,
can be used to cauterize the cornea.
REMEDIES AND THEIR APPLICATIONS. 503
Hot fomentations are used to relieve pain, secure
resolution, or hasten and facilitate suppuration. They
are applied by placing a cloth wrung out of very hot
water upon the eye, and changing it for another equally
hot, whenever it becomes comfortably cooled. Generally
they are continued but a few minutes at a time, such
periods being repeated if needful several times a day.
The temperature that the region of the eye will endure
with ultimate comfort and benefit is often surprisingly
high, especially when it has had a few minutes to become
gradually accustomed to the heat.
Hot Water as a Caustic. — In some cases of ulcera-
tion of the cornea, an excellent influence is exerted by
dropping upon the ulcer one or two drops of water as
near the boiling temperature as possible. To do this,
the eye is prepared for the application. Then the one or
two drops of water are held in the pipette over a lamp-
flame until just at the boiling point, and then dropped on
the ulcer as quickly as possible. The prolonged use of
very hot applications in cancer will sometimes destroy
the morbid tissue. A sponge wet from minute to minute
with boric acid solution, as hot as can be borne, is held
to the part twenty minutes of every two or three hours.
Hot Water as a Styptic. — The best agent to check
bleeding after enucleation of the eyeball, or removal of a
tumor, is hot water. It may be applied by wringing it
out of sponges as hot as can be borne, so as to fall in a
stream on the bleeding area ; or it may be better applied
from a large pipette, such as is used for washing the con-
junctiva. It seems to exert no deleterious influence on
the conjunctiva or wound-surface, even when so hot that
the neighboring skin must be carefully guarded from the
overflow, for fear of its being burnt and blistered.
Poultices must be used with caution about the eye,
since they may aggravate conjunctival and corneal in-
flammations, or favor disastrous intra-ocular suppuration.
Sometimes as for a stye or other lid-inflammation, the
suppurating point may be covered by a poultice so ad-
504 HEAT.
justed as to leave free a large part of the lids and the
fissure between them.
Cold is used upon the eye to prevent or lessen the
reaction after injury, and to combat acute inflammation
in its early stages. It is contraindicated when there is
risk of sloughing of the cornea, or when its application
causes serious discomfort. To do good the application of
cold must be continuous. A common method is to place
by the patient's head a block of ice upon which are laid
three or four pieces of surgical lint, or small cloths. One
of these is laid upon the closed lids for a minute or two,
until it becomes a little warm, when it is replaced by
another piece and laid back on the ice to cool again.
Cold may also be applied by pounded ice in a small,
light, rubber bag, or by ice-water run through a coil of
lead or rubber tubing.
THE MAKING OF APPLICATIONS TO THE CONJUNCTIVA.
Conjunctival Instillations. — Solutions are dropped
in the conjunct! val sac, either that they may be absorbed
through the cornea and thus reach and influence the
interior of the eye, or for their direct action on the con-
junctiva itself.
To affect the interior of the eye it is important that
the solution should reach the cornea undiluted. The
best effect is obtained by having the patient look down-
ward, fixing the gaze on some point on the floor and star-
ing fixedly at it with the other eye. The upper lid of
the eye in which the solution is to be placed is then
gently raised by slight traction on the skin of the lid
with one finger of the left hand, and retained thus by
pressure of the skin against the upper margin of the
orbit. If the patient's head rests against a firm support
where he cannot draw back from this pressure, it is easy
thus to control the movements of the lid. The patient's
head should be tilted back so far that when the upper lid
is drawn up the lashes will be out of the way.
With the ordinary rubber-bulb pipette or medicine
REMEDIES AND THEIR APPLICATIONS. 505
dropper, the required drop or drops are then deposited
on the upper margin of the cornea. They should not
be allowed to fall any considerable distance, on account
of the increased shock from the force with which they
will strike the eye. On the other hand, the dropper
should not touch the patient for fear of infection. An
instillation will be more agreeable if the solution is
brought to blood heat, or a little warmer, before applying
it. After the application, the lid is to be held open until
the patient so far regains control over his eyes that he
can again hold them open without assistance.
To Affect the Conjunctiva. — If the drops are intended
not for corneal absortion but to influence the conjunctiva,
the patient may be allowed to roll the eyes up, the lower lid
being drawn down by the finger pressed against the mar-
gin of the orbit, forming a cup in which drops may be
placed. Such an application can be made most effectively
when the patient is lying down. The lower lid being
still drawn from the globe, the eye should be rolled in
various directions until the solution is diffused through-
out the conjunctival sac. As soon as the lids are allowed
to close tightly, much of the solution will be expelled.
When it is desired to prevent fluids placed in the con-
junctiva from passing with the tears into the nose, as to
prevent the constitutional effects of a mydriatic through
its absorption from the mucous membrane of the nose
and throat, gentle traction should be made on the lids
near the inner canthus, in such a way as to turn the
puncta away from the eye, and a pledget of absorbent
cotton held in contact with the puncta. Simple pressure
upon the canaliculi, through often recommended, unless
so strong as to be very unpleasant, is probably of little
avail for this purpose.
The eye-douche may also be used to make applica-
tions to the conjunctival sac. The solution is placed in
it, and the eye applied to it and opened. On throwing the
head back the solution enters the conjunctival sac.
Washing Out the Conjunctiva. — The water or
solution used should be at blood-heat or warmer. The
506 WASHING THE CONJUNCTIVA.
patient's head should be thrown far back. The patient
or an assistant should hold a mass of absorbent cotton to
the cheek so as to catch the overflow of fluid. The
pipette should have rather a large opening, and a bulb
holding one or two fluid ounces. The upper lid should
be drawn away from the eyeball by the lashes, and the
solution driven into the conjunctiva! sac with something of
a spurt. This is repeated with the stream directed toward
the middle and each end of the upper fid, along the lower
lid, and into the canthus. The escaping fluid is then to
be wiped away, and the process repeated as often as
necessary.
Applications of Astringent and Caustic Solu-
tions.— When the solution to be applied to the conjunc-
tiva is so irritant that it would be unsafe to freely instil
it, it is applied by means of a mop made by twisting a
little absorbent cotton around the end of a tooth-pick, or
match-stick. This is dipped into the solution, and any
excess is pressed out against tlte side of the bottle. The
lid is everted, as for examination (see page 57). The
eye is turned strongly down while the application is made
to the upper lid, and up for the lower lid. The applica-
tion having been thus made to the exposed portion of the
lid-surface, the lid is to be turned in, and with the eye
still turned downward, the upper lid is pushed back as
far as possible under the brow ; and a similar manipula-
tion practiced for the lower lid. This makes the part of
the lid reached by the mop a carrier of the remedy into
the retrotarsal fold which cannot be so reached. The
strength of an application can be regulated largely by the
dryness or saturation of the mop.
Solid applications to the conjunctiva are made
after similar exposure of the membrane by eversion of
the lids. The surface applied to the conjunctiva must
be smooth, and not applied with unnecessary force. To
get a strong effect, the application must be made slowly
to give the solid time to dissolve. Where a slight effect
is sought, the surface may be dried or partly dried and
touched lightly.
REMEDIES AND THEIR APPLICATIONS. 507
Medicated gelatin disks are applied by dipping
in water to soften their edges, and then with a camel's-
hair brush laying the disk on the scleral conjunctiva near
the upper outer margin of the cornea. The eye is then
to be closed for several minutes.
Applications to the conjunctiva in children,
who are liable to resist, or by a sudden movement of the
head to endanger the eye, should be made thus : The
child is seated on the lap of the assistant or parent with
its back to the surgeon, who spreads a towel or oil-cloth
apron upon his knees, and then takes the child's head
between them. The assistant controls the child's hands
and legs ; and the surgeon can hold the head perfectly
secure and steady between his knees, while having both
hands free for use in making the application.
Subconjunctival injections are made with the
hypodermic syringe, through a fine needle. After the use
of a local anesthetic, the conjunctiva is seized with fixa-
tion-forceps, just back from the corneal margin. The
point of the needle is thrust fairly into the loose subcon-
junctival tissue, and the required number of drops,
usually 2 to 6, gently expelled. The patient's head
should be firmly supported. Some of the solutions used
cause severe pain. The needle is quickly withdrawn, and
the lid pressed for a minute or so against the point of
puncture to retain the fluid, and diffuse it throughout the
adjoining loose tissue.
ANTISEPTIC AND CLEANSING SOLUTIONS.
Heat, the most generally reliable of antiseptic agencies,
may be applied to solutions liable to be contaminated, by
repeatedly bringing them to the boiling-point, or by boil-
ing for five minutes whenever used in the eye.
Water is the most important ingredient of all antisep-
tic solutions. The thorough washing away of infectious
materials, and of what may serve as a nidus for patho-
genic bacteria, is far more important than the chemical
action of any solution that can be safely used in the con-
junctival sac ; for it is of prime importance that such
508 ANTISEPTICS.
solutions, which must be used freely to be effective, shall
not be in any way injurious.
Hydrogen dioxid (peroxid of hydrogen) as fur-
nished in 3 per cent, solution (Aqua Hydrogenii Dioxidi,
U. S. P.) is the best agent to cleanse freely opened abscess-
cavities or sinuses, the liberation of oxygen wherever it
comes in contact with pus forcing out the contents of
small pockets and folds. It is also a powerful styptic.
Potassium permanganate is used in disinfecting the skin
or conjunctiva! sac, and as a cleaning wash in purulent
conjunctivitis. In the strength of 1 : 2000 it may be used
freely, but strong solutions are quite irritant.
Fonnaldehyd in saturated 40 per cent, solution in
water, called formalin, is a powerful antiseptic, but very
irritant. Dilutions from 1 : 20 to 1 : 200 may be used to
cauterize corneal ulcers. Solutions of 1 : 500 to 1 : 2000
are effective in cleaning abscess-cavities and sinuses, and
for disinfecting the skin of the lids and the eyelashes
prior to operation.
Formalin, l-(TUj);
Distilled Water, 2000. (f |iv) ;
may be used to cleanse the conjunctiva in purulent con-
junctivitis, although even this causes considerable smart-
ing. A solution of 1 : 4000 is preferable for cleansing
the conjunctiva prior to operation. Formaldehyd is the
best chemical disinfectant for surgical instruments. (See
Chapter XIX.)
Trikresol is one of the least irritating of reliable ger-
micides. The following solution may be made the men-
struum for collyria, and will prevent their contamination
by bacterial growths :
Trikresol, 1. (mj) ;
Distilled water, 1000. (f gij).
Or a solution of double that strength may be used to
rinse the pipettes and to keep them in.
REMEDIES AND THEIR APPLICATIONS. 509
Mercuric chlorid (bichlorid of mercury, corrosive
sublimate) may be used in washing out abscess-cavities
and sinuses, and for cleansing the skin of the lids. The
proper strength is
Mercuric chlorid (corrosive), 1. (gr. j) ;
Distilled water, 1000. (f 3ij).
For use as a wash in the conjunctiva it should have a
strength of not over 1 : 5000, and is best replaced by less
irritant solutions. In the strength of 1 : 500 it is applied
to the inner surface of the lids for trachoma.
Mercuric iodid (biniodid of mercury) is used as an
antiseptic wash, in what is called Panas' solution :
Mercuric iodid, 1. (gr. ^)-
Absolute alcohol, 400. (fag) ;
Distilled water, to make 20,000. (f gvi).
Mercuric cyanid is similarly employed in the
strength
Mercuric cyanid, 1. (gr. j) ;
Distilled water, 5000. (f §x).
CONJUNCTIVAL APPLICATIONS.
Silver nitrate is used in the Crecle method for des-
troying the virus of ophthalmia neonatorum, by dropping
into the eyes of the new-born child a few drops of the
following solution
Silver nitrate, 2. (gr. x) ;
Distilled water, 100.
A solution of the same strength, or two or three times
this strength, is applied to the lids once every one or two
days in purulent ophthalmia, during the period of profuse
purulent discharge. After the application of one of these
solutions the excess is often neutralized by a solution of
sodium chlorid. But it is better to have no excess. The
severity of the application is readily modified and con-
510 CONJUNCTIVAL APPLICATIONS.
trolled by the saturation of the cotton applicator. Numer-
ous solutions of slightly different strengths are therefore
unnecessary. One solution, weaker than the above, is
useful for catarrhal conjunctivitis, as the following :
Silver nitrate, 1. (gr. ij);
Distilled water, 250. (f 3j).
Organic salts of silver, recently introduced as sub-
stitutes for the nitrate, are less irritant ; but their thera-
peutic value is not yet so well established. The principal
one is protargol a combination of silver with a proteid
base. It is stable and freely soluble.
Protargol, 1. (gr. x) ;
Distilled water, 50.
may be used as a collyrium in conjunctivitis, or to
cleanse the lacrimal sac in dacryocystitis. A 20 per cent.
solution is used as an application to the everted lids in
purulent conjunctivitis.
Argyrol is the least irritant of the silver salts, its use
commonly causing no discomfort whatever,, It may be
employed in solutions of from 2 to 40 per cent. The
solution should be fresh. It is said not to be reliable
after two weeks.
Pyoktanin is a name applied to both the aniline dyes
methyl violet (blue pyoktanin) and auramin (yellow
pyoktanin). They are chiefly useful in chronic inflam-
mation of the lacrimal passages. The following may be
used as a collyrium or to cleanse the passages :
Methyl violet, 1. (gr. j) ;
Distilled water, 1000. (f sij).
Boric acid solution is used slightly weaker than a
saturated solution.
Boric acid, 1. (gr. xij) ;
Distilled water, 40. (f gj).
It must be made sterile by boiling. When prescribed as
REMEDIES AND THEIR APPLICATIONS. 511
a collyrium, rose-water or camphor-water may be used.
It is often prescribed in combination with borax, thus :
Sodium biborate, 1. (gr. vj) ;
Boric acid, 2. (gr. xij) ;
Rose-water, 80. (f Ij).
Sodium chlorid solution is used to cleanse the eye,
wash out the anterior chamber, and to float epithelial
grafts for plastic operations. It is
Common salt, l.(gr. iij);
Distilled water, 160. (f gj).
DUSTING POWDERS.
lodoform, for use in the eye, should be in impalpable
powder. It is dusted in as a dressing for wounds or
after operations.
Boric acid, aristol, and acetanilid may be simi-
larly used. They are free from the disagreeable odor of
iodoform, but it is not certain that either is as beneficial
as iodoform.
CAUSTICS, ASTRINGENTS, AND IRRITANTS.
Arsenic, for the destruction of malignant growths,
may be used :
Arsenous acid, 1. (gr. j) ;
Creasote, 60.(f3J).
This must not be used on a large surface. It requires
three or four days to do its work, and is quite painful ; it
is to be followed by poulticing until the slough separates.
^inc chlorid is used for the same purpose as the
above.
Zinc chlorid and wheat flour, equal parts, are mixed
with a little water to form a thick paste. It may be
spread on the walls of the orbit, when all oozing has
stopped, after removal of the orbital contents for a malig-
nant growth.
Copper sulphate is used in crystal. The crystal
512 CAUSTICS AND ASTRINGENTS.
may be cut or ground into the more convenient form of a
pencil. It should be rinsed and wiped off after using,
and care taken to see that it always presents a smooth
surface. If allowed to remain damp, it quickly roughens.
I/apUS divinus is composed of copper sulphate, potas-
sium nitrate, and alum, each equal parts, fused together
with 2 per cent, of their united weight of camphor.
Mitigated silver nitrate stick is made by fusing
Silver nitrate, 1 part.
Potassium nitrate, 2 parts.
Alum crystal, preferably reduced to the more conve-
nient form of a stick, is an efficient astringent, to be ap-
plied to the evertfcd lids for chronic conjunctivitis. It is
much less irritant than the substances mentioned above.
Solutions of
Alum, 1. (gr. xx);
Distilled water, 25. (f 3j) ;
are also useful in the same cases of chronic conjunc-
tivitis.
Tannin dissolved in glycerin is a most valuable local
application for phylctenular conjunctivitis, and the late
stages of trachoma.
Tannin, 1-(3J);
Glycerin, 8. (f 3j),
is the proportion commonly used. Half this strength
will sometimes be equally effective ; and the official gly-
cerite (U. S. P.) of twice the strength may be employed.
^inc sulphate, the active ingredient of many popu-
lar collyria, has been found especially valuable in diplo-
coccus conjunctivitis. It may be used in
Zinc sulphate, 1. (gr. j) ;
Distilled water, 200. (f siij).
Two or three drops may be instilled once or twice a day.
Solutions either stronger or weaker than this may be
employed.
REMEDIES AND THEIR APPLICATIONS. 513
chlorid is recommended by Gifford for diplo-
coccus conjunctivitis in the strength
Zinc chlorid, 1. (gr. j) ;
Distilled water, 500. (f aj) ;
to be used like the zinc sulphate solution.
Boroglycerid (glyceritum, boroglycerini, U. S. P.) is
used in trachoma and chronic catarrhal conjunctivitis,
usually of full strength, but it may be diluted with an
equal quantity of glycerin.
lodin dissolved in glycerin or petrolatum is to be ap-
plied on cotton to the everted lids for trachoma.
lodin, 1. (gr. vj) ;
Glycerin, 75. (f 3J).
Jequirity, the bean of the abrus precatorius, is used
to excite acute inflammation in trachoma, cither by dust-
ing on the everted lids an extremely fine powder, or by
painting them with a 2 per cent, infusion.
OINTMENTS.
Yellow oxid of mercury is an impalpable powder
prepared by precipitation. Chemically, it is mercuric
oxid, the same as the red oxid, which is unsuitable for
application within the eye because of its crystalline char-
acter. The official ointment (U. S. P.) is too strong (10
per cent.), but may be used properly diluted.
Yellow oxid of mercury, 1. (gr. j) ;
Petrolatum (soft),' 60. (§) ;
is a good strength to begin with. But it may do best if
only half this strength, or of considerably greater
strength. The preparation is liable to alter by prolonged
exposure to light.
Boric acid ointment is of value, with massage of
the lids, for trachoma. It may be made :
Boric acid, 1 . (gr. vj) ;
Lanolin (Adeps Lanse Hydrosus,
U.S. P.) 10. (3 j).
33
514 OINTMENTS.
lodoform ointment may be used instead of the
powder :
Precipitated iodoform, 1. (gr. v j) ;
Petrolatum, soft, 10. (3j).
2£inc ointment is an excellent protective ; but for
use about the lids the official ointment (U. S. P.) of 1 to
5 may with advantage be diluted with once or twice its
weight of lanolin.
ANESTHETICS.
General anesthesia is now required in ophthalmic
surgery mainly for enucleation of the eyeball, removal of
orbital tumors, ffcr important operations on inflamed eyes,
as iridectomy for glaucoma, or extensive use of the cau-
tery. Ether is the safer anesthetic, except for brief oper-
ations, where somnoform will produce sufficient anesthesia
without requiring to be repeated. Where the cautery is
used, chloroform must be employed, because it is not
inflammable.
I<ocal anesthesia sufficient for most operations on
the eye is produced by the instillation of cocain or holo-
cain. For foreign bodies in the cornea, pterygium and
similar operations involving only superficial structures,
the anesthesia thus produced is perfect. For operations
on the ocular muscles only the pull on the tendon is
necessarily painful. Chalazion operations, and others in-
volving the lids, are not rendered painless by such instil-
lations. Cataract operations, and iridectomies on eyes
free from inflammation, usually cause little discomfort.
For these latter operations cocain should be first instilled
about fifteen minutes before commencing the operation,
and the application repeated once or twice at intervals of
five minutes. For more superficial operations the time
after the first instillation need not be more than five
minutes ; operation should be completed in about twenty
minutes after the last application, since by that time
anesthesia is diminished. Cocain causes drying of the
cornea and softening of the eyeball. Holocain is free
from the above disadvantages, and it produces anesthesia
REMEDIES AND THEIR APPLICATIONS. 515
more quickly, but its influence is more brief. Cocain
constricts the vessels and lessens hemorrhage, holocain
does not.
Cocain may be used in solutions of from 2 to 10 per
cent., the stronger for operations on the lids, or upon
inflamed eyes, on which it produces comparatively little
effect. A good solution for general use is
Cocain hydrochlorate, 5. (gr. iij) ;
Distilled water, 100. (f 3J).
It should be fresh or freshly sterilized with heat.
Holocain is used in
Holocain, 1. (gr. j) ;
Distilled water, 100. (TH- 100).
It is decidedly antiseptic, such a solution inhibiting
and destroying the pus-organisms coming in contact with
it.
Bucain is a local anesthetic which causes too much
irritation when applied to the conjunctiva, to be gen-
erally used in ophthalmic surgery.
Stovain is used in 2 to 4 per cent, solutions, which
are not damaged by boiling. It does not produce anemia
of the part, but may cause disturbance of the corneal
epithelium.
Alypin is used in 2 to 5 per cent, solution, which is
not impaired by boiling ten minutes. It produces super-
ficial hyperemia of the parts, and may cause corneal trans-
udation if used freely.
Infiltration anesthesia is produced by injecting into
the part a weak saline solution, as one of sodium chlorid
1 ; cocaine hydrochlorate 1 ; and distilled water 500. A
drop or two is injected into the skin, causing a small
wheal. The needle is then withdrawn, and reinserted in
the edge of the wheal, which is already anesthetic. A
drop or two more is injected here, and thus the area of
anesthesia extended until sufficiently large. For deeper
anesthesia, deeper injections are made through this area.
516 ANESTHETICS.
In the thin vascular tissue of the lids, the injections must
be made quickly to secure satisfactory anesthesia.
MYDRIATICS.
Cocain hydrochlorate is the best mydriatic for pro-
ducing brief dilatation of the pupil in the dark room.
It gi\res wide dilatation in the dark room while not
destroying the reaction to light, or materially lessening
the power of accommodation ; so that it causes the patient
little annoyance. It produces wider dilatation of the
senile pupil than the other mydriatics, and with much less
risk of causing glaucoma. A drop of the ordinary anes-
thetic solution may be used from 40 to 50 minutes before
it is required to have the pupil dilated. Its influence
passes off in twelve hours.
Euphthalmin hydrochlorate in 5 per cent, solution
dilates the pupil almost as much as coeain, and produces
rather more weakening of the accommodation. The dila-
tation it causes is maintained in strong sunlight, and re-
covery from its effects requires about twenty-four hours.
It is the best brief dilator of the pupil for examination
in a strong light.
Homatropin makes a good dilator of the pupil ; the
effect of which passes off in about one day if used in the
following solution :
Homatropin hydrobromate, 1. (gr. j) ;
Distilled water, 500. (f gj).
Cocain and homatropin make a most satisfactory
mydriatic in this combination :
Cocain hydrochlorate, 4. (gr. j) ;
Homat. hydrobromate, 1. (gr.
Distilled water, 1000. (f si
Atropin is better where it is desired to keep the pupil
continuously dilated, as for nuclear cataract.
Atropin sulphate, 1. (gr. \) ;
Distilled water, 2000. (f 3j).
REMEDIES AND THEIR APPLICATIONS. 517
A single drop instilled once every two or three days
will answer the purpose. (See also Cycloplegics.)
CYCLOPLEGICS.
HomatfOpin is the best cycloplegic for diagnostic
purposes. The solution used is :
Homatropin hydrobromate, 1. (gr. iij) ;
Distilled water, 40.
A drop of this solution is instilled in the eye every five
minutes until four to six have been thus applied. The
maximum effect is produced in one hour. Recovery
begins an hour or two later, and is usually complete in
forty-eight hours. The instillations should be carefully
made by the surgeon, or a trained assistant. So used,
homatropin is a reliable cycloplegic not likely to cause
constitutional symptoms.
Atropin sulphate exerts the most prolonged control
over the xjiliary muscle. It is therefore fitted for use
when the accommodation is to be kept continuously in
abeyance, and the 6ye given a period of mydriatic rest.
It is especially indicated when the instillations are to be
made by unskilled persons, who may fail to make some of
them effective. The strength used for this purpose is :
Atropin, 1. (gr. iv);
Distilled water, 120. (f 3j).
One drop of this is instilled three times a day.
Duboisin, hyoscyamin, and scopolamin salts are
used for practically the same purposes as atropin. They
resemble each other very closely in their action, and have
the special advantage over atropin of a shorter period of
recovery. Weight for weight they have more than twice
the physiological effect of atropin. The usual solutions
are :
Hyoscyamin hydrobromate, 1 . (gr. j) ;
Distilled water, 300. (f 3v) ;
518 CYCLOPLEGJCS.
Or
Duboisin sulphate, . 1. (gr. j);
Distilled water, 240. (f 3iv).
The above are used as the cycloplegic atropin solutions,
one drop in the eye three times a day.
Scopolamin hydrobromate, 1. (gr. ss);
Distilled water, 1000. (f 3j) ;
is used like the homatropin solution, two or three drops
being instilled, a drop at a time with intervals of five or
ten minutes. Hyoscyamin and duboisin may be used
similarly. If carefully applied, complete paralysis of
accommodation Ls thus produced, with less risk of consti-
tutional symptoms than with stronger solutions, and
recovery occurs in from four to seven days.
Stronger solutions are required to break up adhe-
sions of the iris to the lens-capsule, and to maintain dila-
tation of the pupil in iritis as :
Atropin sulphate, 1. (gr. j) ;
Distilled water, 60. ffm
Or
Hyoscyamin hydrobromate, 1. (gr. j) ;
Distilled water, 120. (f gij).
One of these is to be instilled every five minutes until the
pupil is dilated, or until symptoms of mydriatic intoxica-
tion begin to appear. Eversion of the puncta will hinder
the appearance of the toxic symptoms, and two or three
instillations of a 5 per cent, solution of cocain will increase
the mydriatic effect.
Gelatin Disks. — Homatropin is used, associated
with cocain, in gelatin disks. Used in this way it produces
more effect than the same amount of homatropin used
alone. Each disk contains usually one-fiftieth of a grain
of each drug. Two disks are placed in the eye, fifteen to
thirty minutes apart and allowed slowly to dissolve.
Other mydriatics and the myotics arc also applied in
the same way. But the gelatin disks are not generally to
REMEDIES AND THEIR APPLICATIONS. 519
be preferred to solutions. The disks or lamellae com-
monly used contain :
Homatropin hydrobromate, ^-^ or -^ gr. ;
Atropin sulphate, ^innr; ^ or T^ gr. ;.
Cocain hydrochlorate, 2~5~o or TO &r- j
Physostigmin sulphate, y^o or ^ gr.;
Pilocarpin nitrate, -5-^ gr.
A single disk may be used instead of a drop of one of
the solutions previously mentioned.
MYOTICS.
Physostigmin or eserin (sulphate or salicylate) is a
powerful myotic capable of neutralizing the mydriatic
influence of five times its weight of homatropin. In
young persons it can cause very painful cramp of the
ciliary muscle, and sphincter of the pupil, and on that
account must be used with caution. For instillation in
corneal disease, or to contract the pupil after simple
extraction of cataract it may be used in solution of
Physostigmin salicylate, 1. (gr. ^);
Distilled water, 2000. (f 3j).
To contract the pupil in glaucoma, instillations of this
solution may be first tried ; and then if necessary stronger
solutions may be employed up to 1 : 120 (gr. iv to f 3j).
The weakest solution that will produce moderate contrac-
tion of the pupil is the one to be chosen. As an ocular
tonic, still weaker solutions are recommended as
Physostigmin, 1. (gr. ^) ;
Distilled water, 10,000. (f 3j).
Pilocarpin hydrochlorate is a weak myotic, being
able to neutralize only one-fourth its weight of homa-
tropin. It is used in the proportion of
Pilocarpin hydrochlorate, 1. (gr. j) ;
Distilled water, 500. (f sj).
It may be instilled three times a day or less frequently
to contract the pupil in cortical cataract, or as a local tonic.
520 LOCAL APPLICATIONS.
MISCELLANEOUS SOLUTIONS.
Extract of suprarenal body is replaced by prepa-
rations of its active principle, as adrenalin chlorid, etc.
Adrenalin may be used in solutions of 1 : 1000 or weaker.
Intraocular hemorrhage and acute glaucoma have been
ascribed to it.
Dionin may be used once in twenty-four hours <>r
longer, in powder placed in the conjunct! val sac, or in
solutions of O.o to 10 per cent, in distilled water. It
causes burning, followed by hyperemia and chemosis.
Fluorescin solution is used to detect the location
and extent of corneal ulcers. It contains
Fluoresciu, 1.
Sodium bicarbonate, 2.
Distilled water, 100.
A drop of this, placed in the conjunctival sac, quickly
stains green all tissue exposed by the loss of epithelium.
DRUGS USED FOR THEIR SYSTEMIC INFLUENCE.
Mercury most quickly produces its specific effects
when given by inunction. Mercurial ointment (unguentum
hydrargyri, 50 per cent, of metallic mercury) should be
rubbed into the thinner parts of the skin, to the amount
of 2 to 4 grammes (sss to j), once or twice daily. For
exactness, it may be prescribed with each dose separately
wrapped in waxed paper. The rubbing should be with
the slightest friction, and is best done with a glass rod.
It should be continued until the ointment has largely dis-
appeared, at least fifteen minutes. If the friction causes
irritation, the inunction should not be repeated upon the
same part for two or three days.
Calomel is the best form in which to give mercury
when it is 'desirable to obtain a purgative, as well as a
specific, effect. It is given in (loses of 1 centigramme
(gr. Jl) every two to six hours.
The administration of mercury should be promptly
suspended on the appearance of evidence of its action
REMEDIES AND THEIR APPLICATIONS. 521
about the mouth. After these symptoms have subsided,
one of the following slower methods may be resorted to :
The yellow iodid (green iodid) is best given in pill, in
doses of ^ to 2 grains, three times a day, often combined
with opium.
Corrosive sublimate (mercuric chloricT) may be given
in solutions of potassium iodid (which it converts into the
red iodid of mercury), in doses of -^ to ^ of a grain,
three times a day.
Mercury may also be given hypodermically, or by deep
intramuscular, or intravenous injections, once every two or
three days. These are to be resorted to when other
methods of administration fail to check the disease, or
provoke serious mercurial symptoms.
Potassium iodid, to be effective in the lesions of
tertiary syphilis, or in optic neuritis, must be given in
large doses. The rule is to commence with a dose of 10
or 15 grains, given three or four times a day, and to
rapidly increase the dose until the desired effect is pro-
duced, or the physiologic action of the drug is manifest.
This is conveniently managed by giving the patient the
drug in concentrated solution,
Potassium iodid, 1. (3J) ;
Distilled water, 2. (f 3ij) ;
beginning with twenty or thirty drops, and adding two
drops to the dose each day, or at each dose, according to
the urgency of the case. When the coryza, gastric dis-
turbance, eruption, or persistent taste of the drug is
noticed, its administration may be suspended for a day or
two, and then resumed in slightly diminished dose.
Strychnin, when given for toxic amblyopia or optic
atrophy, is most effective administered in ascending doses,
or those approaching the physiological limit. It is most
safely given in solution, or in carefully prepared granules.
Commencing with a dose of -^ of a grain, this may, from
time to time, be increased to 3^, Tg"> T2"> To> an(^ some-
times to ^, ^, or even ^ of a grain, three times a day.
The patient must be kept on his guard against an exces-
522 SYSTEMIC REMEDIES.
sive dose ; and each time a new solution is prescribed the
dose should be at first slightly diminished. When stiff-
ness of the neck or jaws is noticed, or ordinary movements
produce unpleasant jerking within an hour or two after
the taking of the medicine, the dose should be slightly
diminished.
Hypodermically, the dose is about the same as by the
mouth, but it is administered only once a day. It is
gradually increased from day to day until the limit of
tolerance is reached.
Pilocarpin, given to produce sweating, in detachment
of the retina, choroiditis, and vitreous opacity, is best
administered hypodermically. From 2 to 10 minims of
the following solution are injected :
Pilocarpin hydrochlorate (or nitrate), 1. (gr. ij) ;
Distilled water, 30. (f sj).
The patient is then kept warmly covered up in bed for
three or four hours. This may be repeated daily.
COMMON OPERATIONS. 523
CHAPTER XIX.
COMMON OPHTHALMIC OPERATIONS.
GENERAL CONSIDERATIONS.
Preparation of the Patient. — For office operations
the eye should be thoroughly cleansed with boric acid
solution, the lids, lashes, and adjoining parts of the face
having been previously scrubbed with soap and water.
If there be lacrimal or other septic disease it should
generally be treated first. But in emergency-operations,
as removing a foreign body, or iridectomy for prolapse
of the iris, we may have to be content with thoroughly
washing out the lacrimal passages before cleansing the
eye. A weak solution of mercuric chlorid, 1 : 5000,
may be used for this purpose, but thoroughness in the
washing is to be mainly relied on.
House patients should be accustomed to their sur-
roundings, spending one day in the hospital before the
operation, should have the bowels freely opened, a general
bath, and the conjunctiva cleansed repeatedly with boric-
acid solution. The lids and neighboring parts and,
especially the lid-margins and lashes, should be thoroughly
cleansed with soap and water. Any conjunctivitis should
be treated until the eye is free from discharge or undue
redness, before undertaking a cataract or plastic opera-
tion. In cases of lacrimal disease that cannot otherwise
be cured, it may be best, as a preliminary measure to
obliterate the lacrimal sac. When there is lacrimal
disease, and no time to treat it, as in acute glaucoma, the
sac may be thoroughly washed out and the puncta tem-
porarily obliterated by touching them with the actual or
galvanic cautery. They can be reopened after the heal-
ing of the corneal wound. Operations that can be
delayed should not be done during acute bronchitis, or
temporary depression of the general health from any
cause. But extreme age, or feeble health is rarely a
positive bar to success in ophthalmic operations.
524 PREPARATION FOR OPERATING.
Preparation of the Surgeon. — Septic cases should
not be seen for several hours before operating. The
hands of the operator and his assistants should be
thoroughly scrubbed with soap and hot water, the nails,
etc., carefully cleaned, and the scrubbing repeated. They
must then be kept from touching surfaces that have not
been rendered similarly aseptic.
If the operation is one not frequently done, the operator
should go carefully over every step of it in mental review,
or previously practice it on the eyes of lower animals.
He should see that every instrument and appliance is in
place, carefully try the light that is to be used, and
adjust seat or position so that every necessary movement
may be made Avith the greatest ease and freedom, and
without danger of jostling. When operating without an
accustomed assistant, it is best to have all instruments
within the surgeon's reach and to make the temporary
assistant's duties as few and definite as possible.
Preparation of the Instruments, etc. — After use,
and before it has had time to dry, every instrument
should be carefully cleaned with hot soap and water,
special attention being given to all joints, and to rough
instruments to insure that they retain no mass or clot
of infective matter. This should be attended to by the
surgeon himself, or a specially trained nurse or assistant.
The instruments should be kept in a tight case, with
powdered paraform, which gives off constantly formal-
dehyd vapor. Instruments used for cases of suppura-
tion and trachoma should be kept separate from those
used for aseptic operations. Before using, the instru-
ments should be again washed, and the jointed and rough
instruments boiled for two minutes. Knives and other
cutting instruments are to be dipped in boiling water.
The instruments may remain in boiled water, or can be
loosely wrapped in sterile absorbent cotton until wanted.
Another method is, after cleansing, to place instruments
that cannot be boiled in a solution of formaldehyd 5 to 20
per cent, to which has been added 3 per cent, of borax.
In this they remain continuously until required for use.
COMMON OPERATIONS. 525
They are then rinsed in a boric acid solution and wiped
with cotton to remove any deposit, and are ready for use.
Position and Illumination. — For operating on the
eye the patient's head should be about as high as the
lower part of the surgeon's chest, firmly supported, and
with the face directed upward. This position may for
minor operations be attained in a chair, the head resting
on a head rest, or against the surgeon's chest. But for
important operations it is best secured upon a table, the
height of which must be adjusted according as the
surgeon prefers to sit or stand while operating. In oper-
ating upon a bed, the patient must be so that the head of
the bedstead will not interfere, as across the bed or with
his head toward the foot of the bed. The head must be
supported on a firm hair pillow under which a board may
be placed to give additional steadiness.
Generally the light should come from the side of the
eye operated on. The best light is the brightest that can
be obtained short of direct sunlight, coming from rather a
small space,, and in such direction that the surgeon shall
not be baffled by annoying reflections from the cornea.
The conditions to be met are essentially those of a good
oblique illumination. An electric lamp furnished with
shade and condenser is the most manageable source. But
with the patient brought close to a window that opens to
clear sky, an excellent illumination can be arranged by
diffuse daylight. The patient should be brought into
position, and the light carefully tested and adjusted before
beginning the operation.
Retraction of the I,ids and Fixation of the Eye-
ball.— The patient should steadily fix his gaze upon the
proper designated spot ; and by so doing he will lessen the
discomfort of operations done without general anesthesia.
For many operations retraction of the lids and fixation
are best accomplished with the operator's left hand.
Standing behind the patient, the fore-finger retracts the
skin of the upper lid, and fixes it by pressure against the
upper margin of the orbit; while the middle-finger
similarly fixes the lower lid against the lower orbital
526
RETRACTION OF LIDS.
margin. This secures retraction of the lids without pres-
sure on the globe, and the traction on the conjunctiva
tends to steady the globe. To fix the globe more firmly,
pressure must be made with the fingers above and below
the cornea.
When the left hand will be otherwise employed, the
lids must be retracted by a stop-speculum, which is
FIG. 151.— Stop-speculum.
slipped between them and then opened as widely as it
can be without causing pain. The best form is shown in
Fig. 151. Or the lids may be retracted by an assistant
using for the upper lid a retractor such as is shown in
Fig. 152. To protect the eyeball during operations on
the lids the lid-spatula shown in Fig. 156 is employed.
FIG. 152.— Lid-retractor.
When pressure on the globe must be avoided fixation-
forceps (Fig. 153) must be used. For use on the con-
junctiva their jaws should be serrated rather than toothed,
FIG. 153.— Fixation-forceps for seizing the conjunctiva.
and they are to be applied as close to the limbus as pos-
sible where the conjunctiva is most firmly connected with
the sclera. They should make no pressure on the globe.
COMMON OPERATIONS. 527
For siezing upon the firm deeper tissues, fine-toothed for-
ceps are made (Fig. 154).
Sponging1 for eye operations is best done with masses
of absorbent cotton moistened with boric acid solution,
FIG. 154.— Fixation-forceps for holding deeper firm tissues.
and then squeezed dry as possible. These may be
wrapped on sticks six or eight inches long, before moist-
ening, to enable the assistant to keep his hands out of the
way. Blood may also be washed away with solutions of
boric acid or common salt.
DRESSINGS.
Simple Dressing. — To give the eye rest, protect it
from slight temperature changes, exclude mechanical,
chemical and bacterial irritants, and provide for the
absorption of the slight discharge that escapes between
the lids with the least discomfort, without pressure and
without undue local heat, are the indications to be met
by the dressings after an ophthalmic operation.
The author most frequently employs the following : A
few layers of gauze, large enough to cover the orbit, are
laid upon the closed lids, and on these a sufficient mass
of absorbent cotton. This is retained by one or more
strips of adhesive plaster, one inch wide, extending from
the center of the forehead to the cheek, with perhaps one
strip from the temple to the opposite side of the nose.
If the other eye is to be closed a similar dressing is to
be placed over it. If it is desired to have a moist dress-
ing, the gauze may be covered with surgical lint dipped
in boric acid or other solution, and a layer of oiled silk
or rubber protective added over the cotton. When it is
important that the lashes should not stick to the dressing,
it may be smeared with soft petrolatum, or boric acid
ointment.
528 DRESSINGS.
PreSSUre-bandage. — When required, pressure is made
by means of a bandage. A large wad of absorbent cotton
is carefully adjusted to properly distribute the pressure ;
then a roller of elastic flannel, 2 inches wide and 5
yards long, is started upon the occiput, carried under the
mastoid and ear on the side of the affected eye, up over
the eye, high on the temporal region of the side of the
head, and down to the point of starting. The bandage
will be most firm if every alternate turn is carried above
the ear on the affected side and low on the opposite side
of the head. It should be pinned at the points of inter-
section. The bandage will not retain its position well
unless it does make some pressure. It is therefore un-
suitable for use ftfter many operations.
To secure simple closure of the lids, isinglass plaster is
used. A strip of the plaster ^ inch wide is placed on
the palpebral fissure, and one or more strips at right
angles to this, extending from just under the brow down
to the cheek. This dressing, when dry, is likely to cause
some discomfort. Only the thinnest and most flexible
plaster answers the purpose properly.
Ring1 Dressing. — After plastic operations, especially
after skin-grafting, it is best to make a ring of absorbent
cotton, large enough to include the whole field of opera-
tion, and thick enough to support the dressing without its
coming in contact with the new-formed surface.
The I<iebreich bandage was originally a light
knitted bandage secured by tapes ; . but the name has
come to be applied to various forms of thin bandage
fastened by tapes. It may be single (for one eye) or
double (for both eyes). It is convenient, when the dress-
ing must be removed frequently to instil drops or to
cleanse the eye.
Mask Protector. — To protect the eye from injury
by accidental strokes during sleep, as after cataract ex-
traction, a woven wire mask, or aluminum protector, is
sometimes used.
Eye-Shades should be light, and allow sufficient air
to enter around them to keep the covered eye cool and
COMMON OPERATIONS. 529
dry. A nice one is made of aluminum covered with
silk. Buller's shield, to exclude infection while permit-
ting the use of the eye, is described on page 249.
HEMOSTASIS.
In ophthalmic operations and for wounds about the eye,
it is rarely needful to ligate bleeding vessels. Pressure
soon controls bleeding ; so does hot water (see page 503).
Solutions of cocain greatly diminish the bleeding when
that drug is used as a local anesthetic. This action adds
greatly to the value of cocain for operations for ptery-
gium, squint, etc., where bleeding may cause embarrass-
ment. Hydrogen dioxid quickly checks bleeding, but as
the froth it makes would equally embarrass the operator,
it generally cannot be used until the close of the opera-
tion. Extract of suprarenal body applied before pro-
ceeding to an operation will greatly diminish the bleeding.
ABSTRACTION OF BLOOD.
The loose tissue of the lids is so liable to excessive
swelling after a leech-bite, that leeches are usually applied
to the temple, which may be pricked until blood appears
to induce them to bite. Each American leech will draw
about one fluid-dram of blood, the European leech four
times as much.
The artificial leech consists of a circular knife made to
cut with a rotary movement ; and a glass cylinder that
can be exhausted of air by a screw-piston. From one to
four ounces of blood may be taken from the temple with
advantage. In severe ocular inflammations this may
give more relief from pain than any other measure.
OPERATIONS UPON THE LIDS.
The removal of displaced lashes is commonly
effected with forceps such as are shown in Fig. 155. The
tips should close upon one another with perfect accu-
racy. To see the fine white lashes which are most fre-
quently at fault, oblique illumination should be employed.
34
530
REMOVAL OF LASHES.
The binocular magnifier mounted on a head-band is also
of great assistance (see page 69).
For the permanent destruction of the lashes, electro-
FIG. 155.— Epilation-forceps.
lysis is to be practiced by thrusting a fine needle, con-
nected with the negative pole of the battery, as accurately
as possible to the root of the hair (the positive pole being
FIG. 156.— Making the Intel-marginal incision (Hotz).
held in the hand), and allowing a current of 2 or 4 milli-
ampcres to pass through it for five to twenty seconds.
Minute bubbles of gas escape, and the hair should be
found loose in its follicle.
COMMON OPERATIONS. 531
When the lid has become greatly distorted by cicatri-
cial changes, as after trachoma, so that restoration of the
lid-margin to good position is impossible, the best result
may be obtained by excision of the hair-bulbs, " scalping."
The " intermarginal incision" (see Fig. 156) is made just
back of the hair-bulbs, and another incision parallel to it,
and 2 or 3 mm. above it, on the surface of the lid. The
strip of tissue between, including the hair-bulbs, is re-
moved, and the skin and conjunctiva brought together by
fine sutures. The tract is dusted with iodoform and
the eye covered with a light dressing.
Operations for entropion and distichiasis, bear-
ing the names of their originators and modifiers, are suffi-
ciently numerous. And several of them possess parti-
cular advantages for certain cases. The most generally
applicable for entropion of the upper lid is the following :
The upper lid is put upon the stretch, and an incision is
made parallel to the lid-margin, and so far below the
upper border of the cartilage that when drawn up to it
the lid-border will be pulled upon sufficiently to evert all
the lashes. The tissue covering the cartilage, including
the fibers of the orbicularis muscle, is then carefully
removed. The skin attached to the lid-margin is then
drawn up and fastened to the upper margin of the carti-
lage by three sutures, which are afterward carried through
the other lip of the wound, which is thus closed. Iodo-
form is dusted on the line of incision and the whole cov-
ered with a light dressing. After four or five days the
sutures are removed and all dressings omitted.
If such a readjustment would cause much tension on
the skin of the lid-margin, it is well to begin by making
the " intermarginal incision " behind all the lashes ; and
when this is made to gape, by tightening the sutures that
close the incision at the upper border of the cartilage, to
transplant into it a sufficient strip of mucous membrane
from the lower lip, which may be held in place by sutures
passed through it at either end. Frequently the inter-
marginal incision and mucous graft alone will be
sufficient.
JEntropion of the lower lid due to redundant skin is
532 ENTROPION OPERATIONS.
relieved by excision of an appropriate piece of skin and
the bringing it together with sutures, or by producing
cicatricial contraction of the skin with caustic potash (see
page 456).
Canthotomy is done to extend temporarily the pal-
pebral fissure, to prevent irritating pressure and secure
more complete eversion of the lids in conjunctivitis, or
for the relief of fissure of the skin at the outer canthus.
One blade of a pair of strong blunt-pointed scissors is
introduced into the conjunctival sac at the outer canthus,
FIG. 157.— Canthoplasty (Meyer).
the other blade being placed on the skin near the margin
of the orbit. The inner blade must be made to press ex-
actly into the canthus, so as not to cut either lid ; and
while the lids are stretched apart with the thumb and
finger, the tissues are divided at a single stroke. The
incision may also be made with a scalpel or bistoury.
Canthoplasty is done to permanently extend the pal-
pebral fissure. After the incision for canthotomy above
described, the conjunctiva and skin are brought together,
so as to cover the raw surfaces and prevent their reunion.
COMMON OPERATIONS. 533
Three sutures are required. One is placed at the ter-
mination of the incision, the extreme angle between the
lids, where it is most important to secure accurate junc-
tion of the skin and conjunctiva, and one on either side
of this on the upper and lower lids. The sutures should
take a good hold on the conjunctiva, emerge near the
conjuuctival edge of the raw surface, re-enter near the
skin-margin, and take a good hold on the skin without
much of the deeper tissures. The cut with the stitches
introduced is shown in Fig. 157. It is sometimes well
to undermine the skin somewhat to make it closely meet
the conjunctiva. lodoform may be dusted upon the
wound and a light dressing applied to cover it.
The effect of a canthoplasty may be increased by 'divi-
sion of the tarsal ligament. This is put upon the stretch
by pulling the upper lid toward the nose, and then
divided by fine-pointed scissors, the points being in-
troduced between the skin and conjunctiva directly
upward.
Division of the upper lid is practised to relieve
pressure and facilitate the treatment of purulent ophthal-
mia, or to facilitate plastic operations in the upper con-
junctival sac, and prevent subsequent displacement.
With blunt strong scissors the lid is divided vertically
near its center, and each flap is turned up and stitched to
the brow by a suture passing through its angle. After
the purpose of the operation has been served, the edges
of the lid are freshened and carefully brought together
with fine sutures.
Union of the lids (tarsorrhaphy) may be done at the
outer canthus to shorten the palpebral fissure, for passive
ectropion of the lower lid, or lagophthalmos. For this
purpose the lids are drawn together as desired and the
point for the new canthus marked on each. From this
point outward, a narrow strip of tissue, containing the
bulbs of the lashes, is removed from each lid. This strip
may include more of the skin-surface of the upper lid
and more of the conjunctival surface of the lower. The
two lids are then brought accurately together by sutures,
534 UNION OF THE LIDS.
which must include the thickness of the lid and be left
in place until union is firm.
To protect the cornea in exophthalmic goitre, the cen-
tral portion of the lids may be united. In this case the
lashes are left, in the hope that union need be only tem-
porary, The freshened surface includes not less than
half of the inner edge of the lids ; and the stitches must
be deep and well drawn up to secure a sufficiently firm
union, to be of any value.
To secure immobility of the parts for a few days, as
after a wound or plastic operation on the lids, the lid-
margins may be stitched together without freshening their
edges, care being taken to avoid the rubbing of the
stitches against <)he cornea.
Ectropion Operations. — Ectropion, due to thicken-
ing of the conjunctiva, usually affects the lower lid. It
may be treated by removal of the conjunctival and sub-
conjunctival tissue by a V-shaped incision and bring-
ing the edges together by sutures. If the deformity be
too great for that, the incision may include the whole
thickness of the lid and should be brought together with
FIG. 158.— Argyll Robertson's strap-operation for ectropion of the lower lid.
a fine hare-lip pin and sutures. A safer operation, if
applicable, is the removal of a triangular piece at the
outer end of the lid with the formation of a strap run-
ning up on the temple, as illustrated in Fig. 158. The
strap is first cut as indicated by the heavy line, then the
triangle included by the dotted lines is excised and the
lid drawn up in place by the strap and the piece of skin
COMMON OPERATIONS. 535
covered by the strap (see broken line) is removed. The
parts are then brought together with sutures. Ectropion,
through the dragging of scar-tissue, requires some form
of plastic operation.
Plastic Operations on the I<ids. — The replace-
ment of tissue to remedy distortion of the lids caused by
loss of tissue gives scope to the widest experience and
the most ingenious adaptation of means to ends. It
should be undertaken only after careful study of many
different plans of procedure, since any of these may give
hints of especial value in the particular case. It is here
only possible to indicate a few general principles. A suc-
cessful result can only be attained by permanently reliev-
ing the lids of all abnormal tension. They have no sup-
port that enables them to resist even a slight continuous
traction. Skin to replace the lids must be extremely
thin and flexible, or the operation substitutes one deform-
ity for another. On this account, skin from the imme-
diate vicinity of the lids, or from the temple, is better
than from other parts. Cicatricial skin, if its vitality is
good, is also well suited for the purpose (Hotz). The de-
sirable skin may be brought in by sliding flaps. The full
thickness of the skin may be transplanted without pedicle
from distant parts, as the inner surface of the arm, but
there is a liability of subsequent shrinkage of the flap.
The most generally applicable method is that of trans-
planting large epithelial skin- grafts, proposed by Thiersch.
This should be used to cover all raw surfaces in the
vicinity of the lids which may cause subsequent de-
formity.
Epithelial Grafts (Thiersch Grafts).— The surface
to be covered should be free from granulations, and asep-
tic. The skin from which the graft is taken, commonly
the inner surface of the arm, is carefully cleansed with-
out the use of any strong antiseptic. The skin is put
upon the stretch and a shaving removed with a sharp
razor. The razor-blade must be flooded with salt-solu-
tion, to float the graft and prevent it from being broken.
A graft slightly larger than the surface to be covered is
536
EPITHELIAL GRAFTS.
most desirable. It is floated from the razor into position,
and trimmed to the exact size of the raw surface with
scissors. The field of operation is then to be protected
by a ring dressing (page 528), kept warm and moist
with a layer of protective, and left undisturbed for two
or three days.
Ptosis Operations. — Where ptosis is due to hyper-
trophy of the skin or other tissues of the lid, the tissue
obstructing lid-movements is to be excised. If the con-
tractile power of the elevator of the lid is lacking, exci-
sion of a strip of the orbicularis muscle, or of the muscle
with the skin over it, or even including a part of the
tarsal cartilage, may be of benefit. But if the loss of
FIG. 159.— Panas' operation for ptosis (Hotz).
power in the elevator be complete, such excisions do little
good. The connection of the lid with the frontalis mus-
cle, so that by its action the lid can be elevated, is then
to be aimed at. This may be effected by a wire or light
gold chain passed from the tarsus up under the brow, or
by Panas' operation, in which a tongue of skin from the
lid is drawn up under the bridge of tissue formed by
undermining the brow (see Fig. 159). Motais operation
unites a central slip of the tendon of the superior rectus
to the tarsal cartilages, enabling the lid to follow accu-
rately the movements of the eyeball.
COMMON OPERATIONS, 537
Chalasion is excised by making an incision through
the skin over it, parallel to the lid-margin, and carefully
dissecting it out. The operation is facilitated by the use
of a lid-clamp, to prevent hemorrhage. The incision is
closed with a fine suture. This operation is rather tedi-
ous and quite painful.
Incision with scraping and cauterization is a shorter
operation and mostly preferable. The lid is everted with
the lid-clamp or with the fingers. The discolored spot
on the conjunctiva! surface is made prominent, and freely
excised in a direction perpendicular to the lid-border.
The contents are then scraped out with a curette, and the
interior of the cavity touched with a point of copper
sulphate. The cavity fills with blood, which may require
two or three weeks for its entire removal.
OPERATIONS ON THE CONJUNCTIVA.
Pterygium. — Small pterygia may be destroyed by
the galvanic cautery ; or by electrolysis, by passing a
3 milliampere current for one minute through a fine
platinum needle thrust under the growth, parallel to the
corneal margin, and repeating once or twice with the
positions of the needle 2 mm. apart.
Excision begins by dissecting up the pterygium, and
upon the thoroughness with which this is done depends
chiefly the success of the operation. The pterygium
being grasped with forceps about the corneal margin is
cut loose from the cornea with a Beer's knife, care being
taken to go deep enough to leave only normal corneal
tissue, especially at the apex. Prince introduces a stra-
bismus-hook beneath the pterygium, and with it tears loose
the corneal portion. After this part is loosened it must
be seized with forceps and the scleral portion dissected
up, the same care being used to remove all the tissue
down to the solera. When the growth has been dissected
up, incisions are made at the upper and lower margins,
coming together near the caruncle. The conjunctiva
may then be brought together with one or more sutures,
538 PTERYGIUM OPERATIONS.
but sliould not be made to cover the sclera entirely up to
the corneal margin.
Transplantation. — With the scissors, the conjunctiva is
loosened up below the pterygium after it has been dis-
sected back from the cornea, and a thread with a needle
on each end is passed through the apex of the growth.
Both needles are then carried downward beneath the con-
junctiva until opposite the retrotarsal fold, where they
are made to emerge into the conjunctival sac 6 or 8 mm.
apart. The thread, being drawn upon the pterygium, is
dragged down beneath the conjunctiva, and fastened there
by the tying of the thread. This method, suggested by
McReynolds, is superior to transplanting the pterygium
into an open slit in the conjunctiva, or doubling under-
neath upon itself toward the inner canthus. The trans-
planted growth slowly atrophies. A large pterygium
may be excised, and the exposed sclera covered by a
graft of mucous membrane from the lower lip.
Symblepharon operations usually aim at covering
with epithelium the surface exposed when the eyeball is
dissected free from its adhesions to the lid. This may
be done by grafts of skin or mucous membrane, or, in
some cases, by sliding-flaps of conjunctiva, or by turning
in a skin-flap. The epithelial grafts may be spread upon
an artificial eye, which when inserted will retain them
in proper position until firmly adherent.
Epithelial grafts of mucous membrane may be
obtained from the conjunctiva of the rabbit, but will com-
monly be taken from the under lip of the patient. The
surface having been prepared for its reception, the lip is
grasped by fenestrated forceps, which put a portion of its
mucous surface on the stretch and turn it out so that an
epithelial flap can be cut with a razor, as in epithelial
skin-grafting. This flap is similarly floated into position,
pressed into place by moistened cotton swabs, and allowed
to dry for a few minutes before the lids are closed. Both
eyes are closed for the first day or two, and after that
the operated eye is closed for three or four days. Such
flaps come to resemble the conjunctiva in appearance,
COMMON OPERATIONS. 539
while skin-flaps always remain white, and on the eyeball
are somewhat disfiguring.
Trachoma Operations are designed to expel the
peculiar infiltrate that characterizes the disease. They
should be thorough, and done under general anesthesia.
Knapp's roller-operation is preferred. The upper lid
is everted (see page 58), and the fold thus formed is
grasped with fixation-forceps, and turned out so as to ex-
pose the retrotarsal fold. One blade of the roller-forceps
(Fig. 160) is then thrust into the fold, the other is ap-
plied to the everted surface of the lid, the two are pressed
firmly together, and as they are pulled away, press out
the gray gelatinous exudate. The rollers are then ap-
FIG. 160. — Knapp's roller-forceps for trachoma.
plied to a slightly different portion, and the movement
repeated, until the conjunctiva is free from granules and
the lid-tissues very soft and flexible.
To clear the parts near the lid-margins and commis-
sures, one roller is placed in the conjunctiva, and the other
upon the skin-surface. Thus every part of the fold of
transition, and even the periphery of the ocular conjunc-
tiva, can be brought within the grasp of the forceps.
Care should be taken not to include and disturb the ocular
conjunctiva more than is necessary, and to see that the
rollers turn freely, so as not to drag and tear the con-
junctiva. After the rolling is finished, the parts are to
be cleansed with boric acid solution. The operation is
followed by swelling and discoloration of the lids, which
may be kept down by the use of ice for a few hours.
Relief is marked within the first two or three days, but
additional treatment must be used to complete the cure.
Peritomy may be done for pannus when it continues
after the lids have been rendered comparatively smooth.
540 PERITOMY.
It consists in the removal of a strip of conjunctiva and sub-
conjunctival tissue around the circumference of the cornea.
The strip removed should be 4 or 5 mm. wide, an in-
cision being made that distance from the corneal margin,
and the tissue thoroughly scraped away down to the
sclera. Usually the tissue is removed all around the
cornea, but sometimes the removal may be confined to a
part of the limbus a little greater than that through
which vessels enter the corneal tissue.
OPERATIONS ON THE LACRIMAL PASSAGES.
Syringing of the passages is done either through the
normal canalimilus, after slight dilatation of the punc-
tum, or through the slit canaliculus. The tube to be in-
troduced through the punctum should be about the thickness
of a No. 2 Bowman's probe having an outside diameter
of little over l millimeter, and may be curved to 90
degrees. The tube to be used after slitting the canaliculus
should be rather conical, about 1.5 mm. in diameter at
the tip, and enlarging rapidly from this so as to fill the
opening into the sac whatever its size. The ordinary
hypodermic syringe, or a dental syringe, can be used, but
it is better to have one the barrel of which holds two
fluid-drams. It must not leak either at tube or piston,
for in some cases the obstruction may be overcome by the
use of moderate persistent force ; and it is safe to use
thus what force can be applied without causing serious
pain. For solutions of silver nitrate a gold tube or a.
glass syringe may be employed.
Slitting the canaliculus is done for misplacement
of the punctum and as a preliminary to treatment of
obstruction of the nasal duct. It is done with a knife
having a probe-point, which is made to enter the punc-
tum, and being pushed along the canaliculus, this point
guides the knife as it cuts its way into the lacrimal
sac. A finger on the lid keeps it tense against the edge
of the knife. Great care should be taken to evert the lid
in the region of the canaliculus, and to turn the edge of
COMMON OPERATIONS.
541
the knife toward the eyeball so that the cut shall be made
into the conjunctiva, and not in the lid-margin. If
probes are to be passed, care must be also taken to make
a large opening into the sac by
pressing with the point of the
knife as it is withdrawn. A
narrow entrance to the sac hin-
ders the passage of the probe,
causes pain and the risk of
making a false passage.
Probing the Nasal Duct.
— Lacrimal probes are made of
silver, or the larger ones of
aluminum. Bowman's are num-
bered from 1 to 8, Theobald's,
from 1 to 16. No. 1 is .25 mm.
in diameter, No. J6 is 4 mm.
in diameter. The smallest are
chiefly useful in probing the
canaliculi. Those of chief value
for the nasal duct are Nos. 6 to
13. The probe should be given
a curve approximating that shown
in Fig. 161, and the ends should
be bluntly conical.
The canaliculus having been
slit, the patient's head is firmly
supported, the lid is put upon the
stretch, and the point of the probe
carried in the direction of the
slit canaliculus until it is ar-
rested at the inner wall of the
lacrimal sac by the resistance
of the nasal bone. The probe
is then turned so that the lower
end points downward, a very lit-
tle forward, and slightly from the median line. Thrust-
ing it in this direction, with a slight rotary motion, to dis-
engage the point and find most exactly the direction of
(16
FIG. 161.— Theobald's lacrimal
probe.
542 1'ROBING THE NASAL DUCT.
the canal, the chief resistance is encountered at the upper
end of the nasal duct. The point being carried through
by firm, steady pressure, there is still encountered a less
resistance from the grasp of the stricture on the sides of
the probe, until the point comes in contact with the floor
of the nose, or sometimes a bony obstruction at the exit
of the duct.
The operation causes pain, which is only moderated by
previously injecting the passages with cocain solution. In
children and nervous persons it will be better to use a
general anesthetic. It is best to begin with about a No.
6 probe, and in general to pass the largest that can be
passed without excessive force. The probe should remain
in position tweflty to forty minutes. It should be intro-
duced every second day ; and when the largest probe,
usually No. 11 to No. 13, has been used, the intervals may
be lengthened.
Cutting a I/acrimal Stricture. — After the passage
of a No. 6 probe, the Thomas stricturotome (Fig. 162)
FIG. 162.— Thomas stricturotome.
is introduced in the same manner as a lacrimal probe ;
as it is withdrawn the cutting edge is pressed firmly
against the stricture, incising it. When the stricture has
thus been divided, the instrument may be pushed down,
with the blade turned in another direction, the shank being
flexible to allow of this turning, and a second cut made.
Extirpation of the I/acrimal Sac. — An incision
20 mm. long is made parallel to the nose, • half-way
between the inner canthus and the side of the nose, with
its middle point slightly lower than the canthus. This
is carried down until the lacrimal sac is recognized by
its pale or bluish color. The incision is spread by
retractors. The sac is dissected out, going down into the
COMMON OPERATIONS.
543
lacrimal canal as far as possible, arid the duct cut off.
The wound is then closed by sutures. Any mucous
membrane remaining should be removed by curetting.
An easier method, but followed by slower healing, is to
incise the sac, which may then be packed with cotton
saturated with monochloracetic acid ; or, solid silver nitrate
may be placed in it to destroy its lining membrane.
OPERATIONS ON THE EYE-MUSCLES.
Tenotomy is done to lessen the influence of the ten-
otomized muscle on the position of the eyeball, as upon
the internal rectus for convergent squint. With fixation-
forceps the conjunctiva and subconjunctival tissue are
raised in a fold parallel with the corneal margin, over the
insertion of the tendon to be divided, 5 mm. back from
the cornea for the internal rectus, 7 mm. for the external.
This fold is then divided horizontally by snips of the
FIG. 163.— Strabismus-hook.
scissors cutting down to the sclera. A strabismus-hook
(Fig. 163) is then introduced, with its point pressed firmly
against the sclera below and behind the insertion of the
tendon, and passed upward until it includes the upper
FIG. 164.— Stn
is-scissors.
margin of the tendon. It is then drawn upon sufficiently
to put the tendon slightly on the stretch. Blunt-pointed
strabismus-scissors (Fig. 164) are then passed with one
blade in contact with the hook, and the other beneath the
544 TENOTOMY.
conjunctiva, but in front of the tendon, and by successive
snips the included part of the tendon is divided. The
hook is then turned with the point down, so as to make
sure to include the lower part of the tendon, and this is
fully divided. Sometimes side slips of tissue connecting
the tendon with the sclera must also be fished up with the
hook and severed. When all limiting fibers have thus
been divided, the hook can be readily drawn forward to
the corneal margin.
Partial tenotomy differs from complete in leaving a
thin strand of tissue standing at each margin of the ten-
don, which can be stretched with the hook to the desired
state of relaxation.
Extended tenotomy may be practiced for excessive
convergent squint with marked limitation of outward
movements. After completing the tenotomy of the inter-
nus, the strabismus hook is slipped beneath the tendon
of the superior rectus, the nasal one-half or two-thirds of
which is divided. In a similar manner the nasal portion
of the inferior rectus is divided.
After tenotomy the eye should be cleansed and closed
for a few hours, then left without any dressing. The
effect of a complete tenotomy is usually 10 to 15 degrees;
by extended tenotomy, double that effect may be produced.
Advancement of one of the ocular muscles is done
to increase its influence upon the position of the eyeball.
Thus, in divergent squint, the internal rectus muscle
should be advanced to turn the eye in. When a great
rotation of the eye is desired, advancement of one muscle
is combined with tenotomy of its antagonist. The effect
may also be increased by including in the sutures the
capsule of Tenon and overlying tissue.
To advance the tendon alone, an incision 10 mm. long
is made parallel to the line of insertion of the tendon and
midway between that line and the corneal margin. The
conjunctiva is then undermined to the corneal margin
and back as far as the suture is to be introduced, and the
tendon is isolated that far back. A ligature of black silk,
with a fine needle at each end, is fixed to the globe, by
COMMON OPERATIONS. 545
passing one of the needles beneath the superficial layers
of the sclera parallel to the corneal margin, and quite close
to it, so that the ligature includes 2 or 3 mm. width of firm
scleral tissue. The tendon is then raised on a strabismus-
hook. One needle is carried under the lower edge of the
tendon and made to pierce it from beneath, sufficiently
far back from its insertion ; the other needle is similarly
passed the same distance back beneath the upper edge, so
that the two ends of the ligature shall include between
them about the middle third of the tendon. The two
loops are now drawn safely out of the way, and the ten-
don divided at its insertion. If the end of the tendon
included by the ligature is over 3 or 4 mm. in length, the
excess should be cut off'. The eye is then drawn into
proper position and the stitch tied. The eye is kept
closed for a few hours, and then regularly cleansed. The
stitch is removed in eight or ten days.
Lateral displacement with tenotomy of the superior
rectus is done in paresis of the superior oblique. A
suture is introduced through the tendon and into the
sclera to the temporal side, before the tendon is divided.
When this is tightened,' the tendon is drawn out and
back from its original insertion.
OPERATIONS ON THE CORNEA.
Removal of Foreign Bodies. — A local anesthetic
should be used and the patient convinced by touching of
the eye that the operation will not hurt. He is then
directed to keep both eyes open and fixed in a certain
direction, to bring the eye into favorable position. The
spud shown in Fig. 165 is then placed alongside the
foreign body and pushed steadily between it and the cor-
neal tissue until the foreign body is loosened and dis-
placed, and can be wiped away. Sudden dabbing and
miscellaneous scraping while the patient is rolling the eye
about are to be avoided. Small foreign bodies require the
use of a magnifier (see page 69), and in any case the cor-
neal injury should be examined with a magnifying lens to
see that no particles of foreign substance remain. Any
35
546 FOREIGN BODY IN CORNEA.
softened or probably infected tissue adjacent should also
be scraped away.
Curetting of the cornea is practised for infected
corneal ulcers. After instilling a local anesthetic, all
softened tissue in the ulcer is scraped away with a corneal
spud or spatula. The tissue adjoining the ulcer is also
FIG. 165. — Spud for removing foreign bodies from the cornea.
scraped from the sound tissue toward the center of the
ulcer, to press out whatever infected exudate may be
present in it. This scraping should be repeated so often
as the slightest* extension of corneal infiltration can be
detected.
Paracentesis, tapping of the cornea, is resorted to for
hypopyon, or to relieve intra-ocular pressure, as when a
corneal ulcer is liable to perforate, or a swollen lens is
causing trouble. It is done under local anesthesia
through the lower margin of the cornea. A paracentesis-
needle (Fig. 166), with a thick shoulder to prevent it
from entering too deeply, a broad needle, or the point of
a Graefe knife may be used. The incision is made
parallel to the corneal margin. Care must be taken not
FIG. 166. — Paracentesis-needle.
to wound the iris or lens. The incision may be reopened
by introducing a probe once daily so long as is necessary.
Incision Through Corneal Ulcer (Sacmisch Opera-
tion).— When an infected or sloughing ulcer of the cornea
is extending and likely to perforate, this operation is
done to prevent prolapse of the iris, drain the involved
tissue, and to check the extension of the infection. A
Graefe knife is entered in the sound tissue on one side of
the ulcer with its back toward the iris, carried through
the anterior chamber behind the ulcer, the point brought
COMMON OPERATIONS, 547
out through the sound tissue on the other side, and the
knife made to cut its way out. This makes an- incision
through the whole thickness of the cornea, across the
whole width of the ulcer, which may subsequently be
kept open by probing.
The actual cautery is applied to the cornea to
destroy powder grains, to check the progress of an in-
fected ulcer, or to alter a chronic ulcerative process. A
platinum needle or a fragment of a steel knitting-needle
the size of a No. 6 lacrimal probe may be employed.
The eye being placed under local anesthesia, the needle,
grasped in an ordinary needle-holder, is held in the flame
of an alcohol lamp until its end is white hot, and then is
quickly touched to the point to be cauterized. This may
be repeated several times until the necessary extent of
tissue has been cauterized. The operation is attended
with little pain, unless the hot needle is held too long
close to the eye. Cauterization should be thorough,
destroying all infected tissue, the extent of which may be
previously made more evident by use of fluorescin.
The galvano-cautery may be used for the same
purpose as the above, or to open a corneal abscess or the
anterior chamber, or for conical cornea. On account
of its greater manageability and rapidity of action it is
preferable where many powder-grains are to be destroyed.
The small platinum tip is attached to a handle in which
the circuit can be readily made and broken. The con-
ductors should be light, and so supported as not to drag
on the handle or interfere with the steadiness and accu-
racy of the operator's touch with the cautery point. The
tip should be used at a white heat so as to do its work in
the shortest possible time, before neighboring tissues can
be injured by heat. The necessary current may be ob-
tained by an adapter from the incandescent-light current,
from a storage battery, or from three or four good cautery-
cells. The circuit is made as the cautery tip is brought
near the point to which it is to be applied, and broken
the instant the application ceases. It is better to make
a number of short applications than to attempt to burn
548 APPLICATION OF CAUTERY.
much tissue at a single contact. For conical cornea the
anterior chamber should be penetrated.
Tattooing the cornea is employed to overcome the
unsightly appearance of a corneal leucoma. The eye
should previously be free from irritation, and the tissue
to be colored must be but slightly vascular. India ink
is rubbed in distilled water to a thick paste, spread on the
part of the cornea to be colored ; and picked in, either
with a small flat needle like the Bowman needles, or with
a bundle of fine cambric needles in a special handle, or
bound together so that when held obliquely their point*s
will all penetrate the cornea equally. The punctures
should be as oblique as possible to the corneal surface.
The operation may require to be repeated until the center
is colored black like the pupil, and the other parts gray
to represent the iris. The color may slowly diminish by
diffusion, and requires renewal to keep a black center.
If the operation is aseptic, but slight irritation follows.
Fuchs removes a circle of the anterior corneal surface,
tattoos the underlying tissue, and replaces the circle as a
temporary covering.
Excision of anterior staphyloma (abscission or
keratectomy) may be resorted to, when nothing can be
hoped from iridectomy. With a Graefe or Beer's knife
the staphyloma is transfixed from side to side, the point
of entrance and exit lying fairly behind the staphyloma.
The edge of the knife being directed toward the upper or
lower margin, it is made to cut out, separating one-half
the base of the staphyloma ; the other half is then sev-
ered with slightly curved scissors. Any pieces of thick
hard tissue in the margins of the wound, or tags of loose
hanging tissue, should be trimmed away. The two sides
of the wound may be brought together with three or
more fine sutures, the eye dusted with iodoform, cleansed
twice a day and kept closed under a dressing until the
sutures are removed in from five to ten days.
COMMON OPERATIONS. 549
OPERATIONS ON THE SCLERA.
Anterior sclerotomy is clone for glaucoma. A nar-
row Graefe knife entered 1 mm. behind the upper outer
part of the sclerocorneal junction is brought out at a cor-
responding point of the nasal margin of the cornea. By
a slow sawing movement the knife is made to pass be-
tween the iris and cornea, making a scleral incision until
the bridge of uncut tissue is reduced to about 3 mm.,
when the knife is withdrawn. If the iris prolapses into
either side of the wound, as shown by the pupil becoming
oval, it must be drawn out and cut off.
Posterior sclerotomy is done for glaucoma, detach-
ment of the retina, or for the extraction of a foreign body
or a cysticercus. The point of election is near the equator
of the eyeball above or below the external rectus. But it
may be needful to place the incision under the greatest
detachment of the retina, or most convenient to a foreign
body. The incision is made radially in the direction of
a great circle passing through the anterior and posterior
poles of the eye, with a narrow knife or broad needle.
By slightly displacing the conjunctiva before inserting
the knife, the scleral opening is made subcoujunctival.
The knife may be turned in the wound before withdraw-
ing it, or a spatula may be substituted for it, to allow the
escape of the contents from the interior of the globe.
Unless the incision is very extensive, it requires no
suture.
OPERATIONS ON THE IRIS.
Iridectomy. — Removal of a piece of the iris is an
operation that presents important variations according to
the purpose for which it is done. It is done as a prelimi-
nary to the extraction of cataract, when the pupil is
excessively small, or its margin bound down with adhe-
sions, or there are special risks for a cataract-extraction.
Experience has shown that the risks are slightly less
when the iridectomy is done as a preliminary operation
than when it is done at the time of extraction.
The eye is placed under local anesthesia, the lids re-
550 IRIDECTOMY.
traded with a speculum, and the globe steadied with the
fixation-forceps. The point of a bent keratome (Fig. 167)
is entered at the upper margin of the cornea and pushed
steadily forward, with the plane of the blade parallel to
the plane of the iris, until the corneal incision is suffi-
ciently long, 6 to 8 mm. Then the knife is withdrawn
FIG. 167.— Bent keratome.
without touching the iris or lens, or scraping the cornea with
the point. The iris-forceps (Fig. 168) are introduced into
the corneal incision, opened slightly, made to seize the
iris near its pupillary margin, and withdrawn, dragging
this part of the iris with them. The part of the iris
drawn out is then cut off with one snip of the scissors.
The iris-stump is usually promptly retracted. If caught
in the angles of the wound, it must be carefully freed and
returned within the anterior chamber, either by making
the wound gape by pressure on the sclera, or by stroking
with a spatula from the angles toward the center of the
wound. Blood remaining within the anterior chamber
need cause no alarm, it will be quickly absorbed. The
FIG. 168. — Curved iris-forceps.
eye is then to be closed with a light bandage for a day or
two until the corneal incision has closed. A mydriatic
should be used until the eye is free from redness.
The anesthesia of the iris produced by cocain or holo-
cain is often imperfect. It may be improved by placing
a drop of the anesthetic solution upon the corneal incision
COMMON OPERATIONS. 551
before attacking the iris. But the patient should be
warned that the cut may hurt a little, so that he may
make a special effort to avoid any sudden movement.
The symmetry of the iridectomy depends on seizing the
iris opposite the middle of the corneai incision, and hold-
ing it opposite the center while being cut. The size of
the iridectomy will depend on the amount of iris drawn
into the scissors ; but when the iris returns to its position
it will generally appear larger than might have been ex-
pected. When the iris-margin is firmly bound down to
FIG. 169.— Blunt iris-hook.
the lens-capsule it is more readily freed and brought out
by the blunt iris-hook (Fig. 169) than with the forceps.
Optical iridectomy is required when the natural pupil
is obstructed by opacity of the cornea, partial cataract or
deposit on the lens-capsule. If the eye already possesses
some vision, and especially if the other eye has good vision,
the result of the operation is apt to be disappointing.
The refraction of light is always irregular at the peri-
phery of the cornea and lens, and a portion of the cornea
that looks clear with iris behind it may be found quite
hazy when seen against ah artificial pupil. But if the
patient was previously entirely blind, the restoration of
some sight is very highly appreciated.
An optical iridectomy must be located so as to give the
best vision, where the media are clearest, and where it
will not be covered by the margin of the lid. The best
effect will be obtained by making the opening in the iris
as small as possible, thus reducing the diffusion of light
due to imperfect focussing. If the iris is universally
adherent to the lens-capsule, it will only be possible to get
a clear artificial pupil by extracting the lens.
Iridectomy for glaucoma is best done through a
scleral incision made about 1 mm. outside the margin
of the cornea. At least one-fifth of the iris should be
552 IRIDECTOMY.
removed, entirely up to the ciliary margin. If the eye is
inflamed this should be done under general anesthesia.
On account of the shallowness of the anterior chamber
and the length of incision required, the corneal incision is
made with a narrow knife, used as in cataract-extraction,
to make a puncture and counter-puncture and then to
divide the intervening bridge of tissue. The iris being
drawn well out, one blade of the iris-scissors is introduced
through the pupil behind the iris, and, the iris being
dragged towards one side of the corneal incision, a radial
cut is made in the iris at the other side. The iris is then
torn loose from its ciliary insertion, and at the other angle
of the corneal incision a second radial cut completes the
iridectomy.
6 \9)
ABC
FIG. 170. — Various forms of iridectomy : A, Optical iridectomy for occlusion
of the pupil. B, Small iridectomy preliminary to extraction of the lens. C,
Iridectomy for glaucoma.
The typical colobomas obtained in the different forms
of iridectomy are shown in Fig. 170.
Iridotomy is incision of the stretched iris-fibers, to
make an artificial pupil when the natural pupil has been
closed by inflammation, following an operation or injury
which has removed the crystalline lens. It may be a
simple cut made with a narrow knife perpendicular to the
iris-fibers, or two cuts forming a V made with Wecker's
forceps-scissors, introduced through a corneal incision and
the sharp blade thrust through the iris. A similar opera-
tion including both iris and lens-capsule is called irido-
cysteetomy.
Corelysis, or breaking loose of iritic adhesions, may be
done with a carefully rounded blunt hook introduced
through a small corneal incision and passed behind the
margin of the pupil. Great care should be taken not to
injure the lens-capsule.
COMMON OPERATIONS. 553
Iridencleisis is dragging the iris into a small corneal
incision and leaving it fast there, to give a small and
favorably situated pupil, in cases of corneal opacity. In
iridodesis (iridesis) the small prolapse of the iris obtained
for the same purpose is tied with a delicate silk thread.
OPERATIONS UPON THE LENS AND ITS CAPSULE.
The cataract-knife is usually the broad knife of Beer
(Fig. 171), Sichel and Richter, or the narrow knife of
FIG. 171.— Beer's cataract-knife.
Graefe (Fig. 172). The author prefers the knife shown
in Fig. 173, 3.5 or 4 mm. wide at its widest part.
Simple Extraction.— The lids, conjunctiva, and lid-
FIG. 172.— Graefe's cataract-knife.
margins having been very thoroughly cleansed, local anes-
thesia is produced by not more than three instillations of
cocain, or holocain solution, at intervals of five minutes.
FIG. 173. — The author's cataract-knife.
The patient lies on a bed or table. The operator stands or
sits at his head ; or, if not ambidextrous, at the patient's
left side for his left eye. The lids being held by a spec-
ulum, the eye is fixed by grasping with forceps the
tissue at the lower nasal margin of the cornea. The
patient is also strongly urged to assist fixation by keep-
ing his other eye steadily directed rather downward
throughout the operation. The cataract-knife is en-
554 CATARACT-EXTRACTION.
tered just in the margin of the clear cornea and 1 or 2
mm. above the temporal end of the horizontal diameter,
starting at the position shown by the solid lines in Fig.
174, with its cutting edge upwards and its plane parallel
to the plane of the iris. The knife is then thrust hori-
zontally forward, the point emerging through the counter-
puncture symmetrically placed at the nasal side of the
cornea. The knife is pushed on until it reaches the
position indicated by the broken lines, and is then with-
drawn with an upward pressure sufficient, to divide the
remaining bridge of tissue.
The eye is allowed to rest an instant, before proceeding
to open the capsule. The knife is cleansed with boric acid
solution, and it* back introduced in the corneal incision
until it is almost in the position shown by the broken lines,
(Fig. 174). It is then withdrawn until its point lies in
FIG. 174.— Cataract-incision. The solid lines shovf position of knife com-
mencing the incision. The broken line shows the position of greatest forward
thrust. The remaining bridge of tissue, shown by the dotted curve, is to be
divided as the knife is withdrawn.
the upper temporal margin of the pupil where it is made
to enter the lens-capsule. The knife is now thrust forward
so that its cutting edge makes an incision in the capsule
at the upper part of the pupil, and the edge comes in con-
tact with the upper nasal margin of the pupil. The knife
is then withdrawn, and the eye released from the fixation-
forceps.
Most operators open the capsule with a special instru-
ment, the cystotome, shown in Fig. 175. The point is
introduced sidewise, then turned toward the capsule, and
made to open it by one or more scratches.
The delivery of the lens is accomplished by placing
the back of the lens-spoon against the lower margin of
the cornea, and pressing directly backward. This tilts
the lower margin of the lens backward, and causes the
COMMON OPERATIONS. 555
upper margin to be pushed forward, where it dilates
the pupil and enters the corneal wound. Slight counter-
pressure may be made on the sclera just above the cor-
nea with a spatula, which may also be made to retract
the center of the upper lip of the corneal incision, if
necessary to facilitate escape of the lens. The pressure
is steadily continued, so graduated as to keep the lens
FIG. 175.— Cystotome.
advancing ; but giving time for the sphincter of the pupil
to stretch, and the lens to change shape under pressure.
The pressure must not be intermitted until the widest
part of the lens-nucleus has emerged from the corneal
wound. Then the pressure may be slightly but not en-
tirely relaxed while an assistant removes the lens-nucleus ;
and the surgeon carefully inspects the pupil. If it is be-
lieved that some cortex remains in the lens-capsule, the
pressure is renewed and the lens-spoon is slid up after the
cortical masses ; or the lower lid-margin is substituted for
the lens-spoon until the fragments of cortex are pressed
out.
The iris is then to be returned to its normal position
by making the corneal incision gape by slight manipula-
tion of the globe, or by lightly stroking the iris out of the
angles of the corneal incision. When the pupil becomes
circular and central, the eye is to be cleansed with boric
acid solution and dressed.
Errors and Complications. — The knife in the ante-
terior chamber appears more superficial than it really
is, and therefore the point is liable to emerge too far
back. If this is discovered before the counter-puncture
is complete, or while still quite small, it may be rectified
by slight withdrawal of the knife and change of its direc-
tion. If the iris falls in front of the knife it may often be
gotten off by slightly lifting the cutting edge and then
thrusting quickly forward. If the knife-edge cannot be
556 COMPLICATIONS OF EXTRACTION.
thus freed, the iris must be cut, and the iridcctomy sub-
sequently made regular; or the knife must be withdrawn
and the operation postponed.
If the corneal section is too short, it should be length-
ened with scissors before attempting to deliver the lens,
taking care that the scissors only begin to cut at the end
of the incision, and not into one of the lips of the wound.
To attempt to deliver the lens through too small a corneal
incision is the worst error one is likely to commit. Should
the vitreous prolapse, the nucleus of the lens should be
quickly delivered with a lens-spoon or wire loop ; and the
eye cleansed and dressed without much manipulation to
expel cortex. When much cortex remains, the best way
to extract it i» with a fine stream of boric acid solution,
or normal salt solution, from a special syringe or irrigator.
Lippincott's is about the best. This should be done if
the lens-matter lies in the anterior chamber. But if it is
adherent within the capsule it will be safest to leave it to
absorption or a secondary operation, having warned the
patient that vision will be poor until its removal is com-
plete.
Hemorrhage from the depth of the eye usually destroys
it. It is to be checked by at once raising the patient into
the sitting posture, with the legs dependent, and applying
ice to the eye.
Iris-prolapse. — When the iris does not return to the
anterior chamber, or tends to prolapse when pushed back,
or the pupil will not remain round and central, the iris
should be drawn out with an iris-hook and an iridectomy
done to prevent future prolapse. When the iris prolapses
subsequently, if not promptly reduced, it may be cut off,
best under a general anesthetic. If the prolapse is let
alone and the eye kept under a mydriatic, the healing
will be slow (five to eight weeks), but the ultimate result
will be quite as good as after iridectomy.
After-treatment. — Both eyes are to be covered with
light dressings, which are removed by the evening of the
next day, and the edges of the lids carefully cleansed to
prevent any irritation that would provoke slight move-
COMMON OPERATIONS. 557
ments. This cleansing is repeated daily. The fourth or
fifth day the unoperated eye is usually left uncovered ;
the dressing being renewed on the operated eye until the
end of a week. When the corneal wound has been en-
tirely closed and the anterior chamber re-established for
a day or two, a mydriatic may be instilled.
Delayed union of the cornea! wound sometimes occurs,
generally attended by deficient hyperemia of the eyeball.
Union may promptly follow the discontinuance of the
dressing.
Extraction with iridectomy resembles the opera-
tion above described, except that an iridectomy, as de-
scribed on page 549, is done immediately after the corneal
section ; and the corneal section may be a little shorter.
The operation is free from danger of prolapse of the iris,
but incarceration of the iris in the angles of the wound
is very liable to occur. It is more liable to be compli-
cated by vitreous prolapse.
I/inear extraction is done for cataracts destitute of
large firm muclei. An incision, 6 to 10 mm. long, is
made in the clear cornea, with a keratome or a cataract-
knife. The capsule is opened with the point of the knife
and the soft lens-substance squeezed out.
Suction-operation for fluid cataracts : the needle
of a syringe or suction-curette is introduced through a
small incision in the cornea and capsule, and the lens-
substance sucked out.
Extraction within the capsule is sometimes done.
Its superiority is established only for cases in which the
the suspensory ligament of the lens has undergone atrophy.
Scoop -extraction is performed by passing the wire
loop (Fig. 176), or the lens-spoon behind the lens and
coaxing it out, when pressure cannot be made on the
globe, as when there is prolapse of the vitreous.
Wensel'S extraction may be done when the iris is
universally adherent to the lens. The knife is made to
cut cornea, iris and capsule at one thrust ; and after expul-
sion of the lens, enough iris and capsule are removed to
give a clear pupil.
558 CATARACT OPERATIONS.
Discission is done to secure the absorption of soft
cataract, or to render transparent lens-substance opaque
and facilitate its removal by extraction. It usually re-
quires repetition, in some cases many times, before com-
plete absorption is secured. A knife-needle is the only
essential instrument. It may be either straight or curved.
Its cutting edge should be 3 or 4 mm. long. It must
have a round shank of such thickness that it will just fill
the incision made by the blade. The eye is fixed and the
lids held apart with the fingers ; or speculum and fixation-
FiG.*176.— Wire loop for extraction of lens.
forceps can be used. The eye should be under strong
oblique illumination ; and the binocular magnifier (Fig.
21), is of great assistance. The pupil is fully dilated
with a mydriatic, and a local anesthetic applied.
The knife-needle is introduced half-way between the
center and the margin of the cornea, and a cut made in
the lens-capsule. In a first discission for absorption,
there should be a single cut in the capsule about 3 mm.
long, although the knife may be turned and moved
in the lens-substance as freely as possible without enlarg-
ing the incision. In later operations, when the lens has
been partly absorbed and the eye has shown itself toler-
ant of the operation, more free incisions may be made in
the capsule.
The needle having been withdrawn, the eye is closed
for a few hours with a simple dressing, or absorbent cot-
ton and a Liebreich bandage, and kept under a mydriatic
until entirely free from redness or irritability, and until
all pieces of lens-substance that may fall into the anterior
chamber have been absorbed. Whenever the process of
absorption ceases, as it does in two to ten weeks, the
operation is to be repeated, the lens being each time more
completely broken up. Discission is not devoid of danger.
The slight corneal wound may become the seat of infec-
COMMON OPERATIONS. 559
tion. Hence, strict precautions must be observed to avoid
bruising and to keep it aseptic. If the opening in the
capsule be too large, excessive swelling of the lens occurs,
and may cause glaucoma. If pieces of comparatively
unaltered lens-substance fall into the anterior chamber,
they cause hyperemia of the iris, ciliary body and peri-
corneal zone. Lens-substance that has been previously
disintegrated, by exposure to the aqueous within the cap-
sule, causes less disturbance.
Capsulotomy. — Division of the remaining lens-cap-
sule is necessary, in the majority of cases, to give the best
FIG. 177. — Lines for the T-shaped or inverted V-shaped incision of the capsule
for secondary cataract.
possible vision after removal of the cataract. The opera-
tion differs from discission, as above described, in always
aiming at a free division of the membrane which obstructs
the pupil. On this account, to give the longest sweep to
the cutting edge, to reduce the bruising and twisting of
the needle in the cornea, and to get immediate closure of
the little wound and guard against infection, the knife-
needle should be introduced through the limbus, where
the cornea is overlapped by vascular sclera and conjunc-
tiva. To secure gaping of the opening, it is generally
necessary to make incisions meeting at an angle. ]>ut
after the first has been made, the membrane becomes re-
laxed, so that unless it has been carefully planned, the
second incision may be very difficult to make. A good
plan is illustrated in Fig. 177. The needle entering the
limbus at A is made to pierce the membrane at B, and
then to cut it to C. It is then slightly withdrawn and
made to pierce the membrane at D, and to cut out to £ C,
560 CAPSULOTOMY.
near C. When an extensive adhesion exists between the
iris and the capsule, incisions should, if convenient, pass
through its base, giving freedom to the iris and securing
retraction of the membrane.
If the pupillary membrane be excessively thick and
tough, so that a careful sawing cut will not give a good
opening, it may be torn from the center by double trac-
tion either by two needles introduced at the two margins
of the cornea (Bowman's operation), or by two blunt
hooks introduced from the two sides and caught in a
central slit (Noyes), or a piece may be removed by an
operation similar to iridotomy (page 552). Sometimes the
pupil will contain a thick mass left by imperfect absorp-
tion of the leijs, which is best extracted through a small
corneal incision, by piercing with a sharp hook and
twisting it until it is rolled up and freed from its connec-
tions.
Removal of the lens for high myopia is eifected
by discission to render the lens opaque and lessen its ad-
hesion to the capsule ; and extraction of the mass of lens-
substance, before the swelling of the lens or escape of
lens-matter into the anterior chamber, causes serious
hyperemia. The free division of the lens at the first
operation, advocated by Fukala and others, is attended
by unnecessary danger to the eye, and is followed by slow
recovery. If hyperemia commences it will be better to
extract at once so much as possible of the lens while still
clear, rather than wait till it becomes entirely opaque.
If the bulk of the lens is removed, the portions remain-
ing can swell and disintegrate without causing much
trouble.
OPERATIONS ON THE EYEBALL.
Magnet-extraction. — Magnets used to extract par-
ticles of steel from the eye are of three kinds : Strong
permanent magnets may be used to remove small particles
of steel from the front of the eye, where the magnet can
be brought in contact with them. Portable electromagnets,
like Hirschberg's, have straight and curved points that are
COMMON OPERATIONS. 561
sterilized and introduced into the eye ; where they attract
the particle, which may sometimes be heard to strike
the point with a click. They are then drawn out, with
the foreign body adhering. Very large fixed electro-
magnets were proposed by Haab. They are intended to
attract the particle and draw it out of the eye through
the wound of entrance ; or to draw it around the crystal-
line lens into the anterior chamber, whence it can be
extracted.
For extraction with the portable magnet, the eye and
the magnet-tip having been rendered aseptic, the eye
may be anesthetized and the wound of entrance, if favor-
ably situated, somewhat enlarged. If, however, the par-
ticle has entered through the cornea and lodged in the
vitreous, it will be best to extract through a scleral
incision made as close to the location of the foreign body
as possible. The tip of one of the most powerful hand
magnets (Sweet, Johnson or Lippincott's) should be
introduced just within the incision, and the full current
turned on. If this fails to draw the foreign body to
it, the tip must be thrust more deeply in the direction
of the foreign body, but as little disturbance of the
vitreous. as possible should be aimed at. The "innenpol"
magnet is a form of giant magnet in which the coil
is made large enough for the patient to place his head
within it, and the core to be magnetized is simply a
piece of soft iron of the proper shape, which the surgeon
holds in his hand, very much as he would a hand
magnet.
Knucleation of the Bye. — If the eye be free from
inflammation, this operation may be done under local
anesthesia, although not without some pain. But most
eyes requiring enucleation are inflamed and for them a
general anesthetic is necessary. The lids being retracted
by the speculum, the conjunctiva is seized and divided
around the corneal margin. The conjunctiva is then
pushed back, and with firm pressure the forceps are made
to seize the tissue of the insertion of the internal rectus.
The strabismus-hook is then passed beneath the tendon,
36
562 ENUCLEATION OF THE EYE.
and it is divided with the scissors about 3 mm. back
from its insertion. The stump so left gives a firm hold
for the fixation-forceps. The strabismus-hook is now
passed downward from the insertion of the interims,
breaking up the loose tissue it encounters, until it passes
beneath the inferior rectus tendon, which is hooked up
and divided at its insertion. The hook is then in the
same way passed under the tendons of the external and
superior recti muscles, which are similarly divided.
The anterior portion of the globe having thus been
quite freed from all attachments, the speculum may
be removed and the lids retracted by the fingers. The
eyeball is then strongly rotated outward, and the tissues
pushed back a* the nasal side of the globe until with the
tip of the finger a thick tense cord of tissue is felt, the
optic nerve. The blunt, strong, curved, " enucleation-
FIQ. 178.— Enucleation-scissors.
scissors" (Fig. 178) are now introduced with the points
closed, and made to push aside the tissue on either side
of the nerve. The nerve is then included between the
blades and divided by one strong cut.
The eyeball is now dislocated in front of the lids, and,
while turned out, all adherent tissue is divided close to
the globe by successive snips. The enucleated eye should
be dropped in a 4 per cent, solution of formaldehyd (10
per cent, formalin), to preserve it for subsequent care-
ful examination.
COM l^LICATIONS. 563
To secure increased motility for an artificial eye
Priestley Smith, before doing enucleation, stitches each
of the recti tendons to the overlying conjunctiva, by
raising the tissues with fine-toothed fixation-forceps, and
passing a suture through the fold.
Complications and Cautions. — The removal of an
eye having normal tension and attachments is one of the
easiest of important surgical operations. But if the eye
has been the seat of chronic inflammation, it may be
firmly bound down in all directions by new-formed con-
nective tissue. It may be impossible to reach the inser-
tions of the recti tendons until a zone of this tissue all
around the cornea has been divided by snips with scissors ;
and the tissue between the tendons may be so dense that
in the process of dividing it, the tendons themselves are
divided unnoticed. If the globe has been perforated, and
is therefore perfectly soft, the solera falls in folds that are
liable to be cut with the scissors; and if the eye is
shrunken and soft and surrounded with cicatricial tissue, a
good deal of care is necessary to remove it neatly.
In enucleating an inflamed eye there is always a good
deal of hemorrhage, which must be cleared away by an
assistant during the earlier part of the operation. After
the removal of the speculum, when the optic nerve has
been severed and the adherent tissue is being trimmed
away, the lashes or the lid-margins are liable to be snipped
by the scissors unless carefully guarded.
When the eye is removed because it contains a malig-
nant growth, as much of the optic nerve as possible should
be removed with it. To do this the tissue around the
nerve is pushed aside from it, with the closed points of
the scissors back nearly to the optic foramen, and the
nerve grasped back there by the open blades for division.
The error of enucleating the wrong eye has been com-
mitted.
After-treatment. — Free hemorrhage should be allowed
after this operation, particularly if there has been some
extension of inflammation into tissue surrounding the eye.
When desirable it is best checked by injecting very hot
564 TREATMENT AFTER ENUCLEATION.
water into the socket. The cavity may then be dusted
with iodoform and covered with absorbent cotton. The
socket should then be washed out once or twice daily, and
dusted with iodoform until after four or five days, when
all dressings may be discontinued.
The artificial eye may be fitted as soon as the wound
has quite healed, in the second or third week. Its wear-
ing is to be advised, because beside cosmetic reasons it
prevents the upper lid from falling over the lower, and
being irritated by the lashes. To insert it the upper lid
is drawn out and the larger temporal edge of the shell
slipped up under it. Then the lower lid being drawn
down, the other edge is slipped in and the artificial eye
slides into place. It is removed by pulling down the
lower lid and slipping a large pin under the lower edge.
It should always be removed at night and carefully
cleansed. An artificial eye becomes roughened after one
or two years of continuous wearing, and then must either
be repolished, or replaced by another. In selecting an
artificial eye it should be compared with the natural eye
in a strong light, where a difference of color, or of size of
pupil would be most noticeable. The various forms of
glass eye proposed by Snellen seem distinctly superior to
the older form of a simple shell for use after enucleation.
Evisceration of the eye may be done instead of
enucleation, for pain, as in absolute glaucoma ; or to pre-
vent sympathetic disease, although it is not proven that
for the latter purpose it is equally efficient with enucle-
ation. It should never be done for malignant disease
within the eye. It usually furnishes a better support for
an artificial eye than does enucleation ; but the reaction
and pain following operation are greater, and the healing
is more prolonged.
The eye is transfixed just back of the cornea with a
Beer's or Graefe cataract-knife, which is made to cut its
way out at the upper or lower margin of the cornea. An
incision including the whole cornea is completed with
strong scissors. The contents of the sclera are then
removed, care being taken that no particles of tissue
COMMON OPERATIONS. 565
remain. The cavity may then be allowed to fill with
blood ; or the bleeding may be checked, and the scleral
surface cauterized with carbolic acid, and the cavity filled
with iodoforrn. The sides of the sclera are brought
together by interrupted sutures, or a single gathering-
string suture is run around it.
A layer of surgical lint is laid upon the eye, and iced
cloths applied continuously for a day or two to keep down
the reaction.
Implantation of an artificial vitreous (Mules'
operation) is intended to secure a spherical stump, resemb-
ling a shrunken eyeball, for the better support and move-
ment of an artificial eye. After evisceration a hollow
sphere of glass, silver or aluminum is inserted in the
scleral cavity. All bleeding must first be checked. The
sclera is slit vertically above and below to admit the
sphere, which must not be too large. The sclera is
then brought together in a vertical line by a row
of silk, or silkworm-gut sutures, the angles of tissue
formed above and below being neatly trimmed down.
Then the conjunctiva is brought together over the sclera
by a horizontal row of sutures. If the primary closing
of the scleral opening is incomplete the sphere will not
be retained.
Some operators implant such a globe in the cavity left
after enucleation. Bryant has employed a fenestrated
globe of aluminum, which fills with granulation-tissue,
securing its retention.
A sphere of paraffin, 15 to 20 mm. in diameter,
may be used for this purpose. Sutures are placed in the
tendons of the recti muscles before these are divided.
After bleeding has been checked and the paraffin globe
introduced, the opposing recti are sutured together in
front of the globe, and the conjunctival opening closed
with another set of sutures. This plan is safer and more
reliable than the injection of melted paraffin into the
cavity. The eye of the rabbit has been implanted in the
orbit to furnish support for an artificial eye, but it has
566 OCULAR SYMPTOMS OF DISEASE.
not been demonstrated to possess advantages over the
foreign bodies above mentioned.
Osteoplastic Resection of the Orbital Wall
(Kronlein's Operation], — An incision is made convex for-
ward and downward, beginning above the upper outer
angle of the orbit, passing down close to the external
canthus, and back to the middle of the zygoma; and
carried down to the bone. The periosteum is incised
along the outer margin of the orbit, and the orbital
periosteum separated from the outer bony wall of the
orbit and pushed out of the way with the orbital contents.
A horizontal section of the bone is made, back from the
upper outer angle of the orbit, through the external angu-
lar process oft the frontal bone and the portion of the
orbital wall which separates the orbit from the temporal
fossa. From the posterior end of this section another is
made, downward and rather backward, to the spheno-
maxillary fissure. A third section is made horizontally
backward from the lower outer angle of the orbit to the
spheno-maxillary fissure. The bony flap thus formed,
with the soft parts attached to it, is pushed back from the
temple. The orbital periosteum is incised, and, if neces-
sary, the external rectus divided, permitting free access to
the contents of the rear of the orbit.
CHAPTER XX.
OCULAR SYMPTOMS AND LESIONS CONNECTED
WITH GENERAL DISEASES.
THE detailed descriptions of the symptoms and lesions
here mentioned are given in preceding chapters, and must
be referred to as mentioned here, if the reader wishes to
get a complete clinical picture of the ocular manifestations
of any particular disease.
OCULAR SYMPTOMS OF DISEASE. 567
DISEASES OF THE NERVOUS SYSTEM.
Organic diseases of the brain and its meninges,
including tumor, meningitis, abscess, aneurysm, trauma-
tism, cerebritis, softening, hemorrhage, embolism, and
thrombosis, are all liable to cause optic neuritis (see
page 385). It is therefore of very little value to dif-
ferentiate these various conditions, but it proves that the
symptoms present do arise from organic disease.
Intracranial disease also causes abnormalities of the
pupils (page 72), palsies or spasms of the ocular muscles
(page 204), or limitation of the fields of vision (pages 36, 47,
391), which may be either transient (remote symptoms)
or permanent, directly due to the lesion. When perma-
nent, they are of the highest value in localizing the disease.
The above symptoms in themselves give no positive
information as to the nature of the morbid process caus-
ing them, as whether a tumor is syphilitic or tubercular.
But the close anatomical and physiological relationships
between eye and brain make them often suffer from a
common cause ; and the concomitant eye-lesion may sug-
gest with great probability the nature of the cerebral pro-
cess. Diseases of the retina and choroid are of greatest
importance in this connection.
Optic atrophy attending brain disease, if consecutive
(page 391), has the same significance as optic neuritis.
But if primary it may point to pressure on the tracts or
nerves, in which case it has localizing value ; or it may
indicate that the trouble is of toxic origin (page 397), or
it may belong to a disseminated sclerosis. Progressive
involvement of one ocular muscle after another, or of
different parts of the visual field have great prognostic
significance. The former may characterize a form of
progressive bulbar paralysis. Nystagmus appears fre-
quently in multiple sclerosis, but it may also appear in
any case of prolonged severe impairment of vision. Grave
cerebral hemorrhage, embolism or thrombosis is often
attended with hemorrhage or vascular disease of the
retina of the affected side.
568 DISEASES OF NERVOUS SYSTEM.
SYMPTOMS OFTEN EXPLAINED BY OCULAR
EXAMINATIONS.
Coma should always lead to a thorough objecti\7e ex-
amination of the eyes. If tiremic, albuminuric retinitis
may be found (page 365) ; if narcotic, extreme equal
myosis without other symptoms ; if apopletic, myosis and
inequality of the pupils may be remarked, with conjugate
deviation of the eyes. Organic brain disease may be
revealed by optic neuritis ; or mydriatic poisoning, by
extreme dilatation of the pupils. Convulsions and de-
lirium may be referred to their cause, by the same ocular
symptoms.
Headache^if persistent or frequently recurring, should
always evoke careful investigation of the eyes. Eye-
strain is its most common cause (page 53) ; or it may be
due to organic brain disease that will be revealed by optic
neuritis or atrophy, or to uremia or other conditions that
are attended by characteristic retinitis.
Vertigo, and often nausea, may arise from the causes
mentioned for headache. They may also be caused by
paresis of one or more ocular muscles, or from strain of
these muscles, as in excessive convergence from high
myopia.
Sclerosis of the Spinal Cord. — In posterior sclero-
sis (locomotor ataxia, tabes dorsalis), primary gray optic
atrophy (page 395), with corresponding visual impair-
ment, occurs in between ten and thirty per cent, of all
cases. In a few cases it antedates all other symptoms,
sometimes by many years. Sometimes it appears shortly
after the lightning pains, gastric crises, or ataxic symp-
toms ; and in these cases the progress of the ataxia is apt
to be arrested, and the power of locomotion to remain
good for a long time. Occurring in the later stages, the
atrophy progresses with the ataxia.
In a similar proportion of cases of sclerosis, paresis or
paralysis of one or more ocular mit*cles occurs. This may
also be an early symptom. Such palsies appear suddenly.
They may be quite transient, or permanent. The loss of
OCULAR SYMPTOMS OF DISEASE. 569
light-reflex of the pupil (Argyll-Robertson pupil, page
74), and the less definite condition of rayosis are among
the most important early symptoms of tabes. The former
occurs in three-fourths of all cases, and in very few does
the pupil remain normal. Epiphora is a frequent symp-
tom, being sometimes due to relaxation of the lid, some-
times to hypersecretion.
Acute myelitis has been attended with double optic
neuritis (page 385). In spinal injuries and caries, hyper-
emia and anemia of the disk (pages 383 and 384), have
been noted, but are not significant. Involvement of the
cord or of the nerve-roots in the cervical region may
cause myosis and slight ptosis, through paralysis of the
cervical sympathetic, or spastic mydriasis, widening of
the palpebral fissure, and apparent exophthalmos from an
irritative lesion (page 56).
Disease of the trifacial nerve may be accom-
panied by neuroparalytic keratitis (page 287), or it may
cause herpes zoster (page 288). In all cases of neuralgia
aifecting the ophthalmic division, the possibility of glau-
coma should be carefully considered.
Multiple neuritis may include an axial neuritis of
the optic nerve causing central scotoma (page 40), or may
produce palsies of isolated ocular muscles (page 204).
Epilepsy. — The attack may open with a visual aura,
like that of migraine. There may be concentric narrow-
ing of the field of vision, or lowered acuteness of vision
after the attacks, and sometimes before them. Narrow-
ing of the retinal arteries has been noted at the beginning
of the attack, and marked distention of the retinal veins
at the close, or following the seizure. The ocular mus-
cles may participate in the movements, associated move-
ments of the two eyes being especially common. Sub-
conjunctival ecchymoses may be produced, and partial
opacity of the lens or complete cataract may arise.
Epileptiform seizures seem, in rare cases, to be due to
eye-strain, and to cease when it is relieved.
Tetany has been connected with a form of cataract
570 TETANY.
in which the opacity begins before middle life and is long
confined to the nucleus.
Migraine. — The attacks of pain are in many cases
preceded by scintillating scotoma (page 45), or, in rare
cases, this is replaced by a distinct visual hallucination.
These visual disturbances do not usually occur with every
migrainous attack, but only with an occasional seizure.
Sometimes they constitute the whole attack. They may
attend the attacks for a time, the migraine having existed
before or continuing afterward without any such visual
phenomena.
In a large proportion of cases migraine depends upon
or is aggravated by eye-strain, and is partially or com-
pletely relieved by the careful correction of ametropia
(pages 153, 185). Patients who have the visual disturb-
ance are especially likely to think of their attacks as
connected with ocular defects. But it is not certain that
the connection is closer or more general among these cases
than among others. Optic atrophy (page 391) has some-
times been associated with migraine, but more frequently
glaucoma has been mistaken for such an association.
Chorea. — The acute chorea of childhood, chorea
minor, may be attended with irregular action of the eye-
muscles, but is not caused by muscular anomalies. Habit-
choreas, habit-spasms, or reflex choreic movements, may
be caused by eye-strain and cured by its relief. Severe
eye-strain may also be an important agency in causing the
depressed condition of the nervous system, which predis-
poses to chorea. Retinal embolism (page 374) has oc-
curred in connection with chorea.
Exophthalmic goiter has already been considered
(page 472). The ocular symptoms are not essential, but
are usually the most striking manifestation of the dis-
ease.
Akromegaly. — The hypertrophy may involve the
bones of the orbit and the skin of the lids. The ocular
movements and reactions of the pupils are often slow or
slightly irregular. There may be paralysis of one or
more ocular muscles or impairment of central vision, and
OCULAR SYMPTOMS OF DISEASE. 571
irregular contraction of the visual field (page 41). The
most characteristic ocular symptom, though far from con-
stant, is bitemporal contraction of the visual fields, or
hemianopsia (page 37), probably from pressure of the en-
larged pituitary body upon the optic chiasm. Irregular
or unsymmetrical contraction of one or both fields occurs
from the same cause ; exophthalmos, double optic neuritis,
optic atrophy, nystagmus, and hypersecretion of tears
have been reported.
Mind-blindness, inability to receive a mental im-
pression from objects seen ; word-blindness, inability
to recognize written or printed words ; letter-blindness,
inability to name letters, although words are understood ;
and dyslexia — or an insurmountable difficulty in read-
ing, although the patient possesses perfect sight and can
read a few words at a time — are conditions of important
significance, liable to be confused with impairment of
vision.
Neurasthenia is attended with pain connected with
use of the eyes, variable heterophoria, deficient power of
abduction, adduction and sursumduction (page 192), twitch-
ing of the lids, large but mobile pupils, and persistent
after-images. Concentric contraction of the field of vision,
hyperemia of the optic disk (page 93), and causes of eye-
strain should be "carefully looked for.
Myasthenia gravis generally begins with intermit-
tent ptosis (page 457), most noticeable when the patient
is tired. Paresis of the orbital muscles is common, and
exophthalmos may occur. The symptoms are relieved
by rest, but recur.' It may be fatal.
Insanity may be attended with visual hallucinations.
It presents no ocular symptoms characteristic of the con-
dition in general, or of any particular form of insanity.
Ocular symptoms connected with some causative or con-
comitant condition, like albuminuria, syphilis, or tabes,
are common.
Hysteria may present many eye-symptoms. The
more characteristic of these are progressive concentric
contraction of the field of vision, like that of neura-
572 HYSTERIA.
thenia, contraction of the color-fields or reversal of their
normal order, amblyopia or complete blindness of one
eye (page 403), squint (page 234), blepharospasm, dilata-
tion or contraction of one pupil (page 76), monocular
diplopia without evident ocular cause (page 46), asthen-
opia, and complaints of inability to use the eyes or wear
glasses. Eye-strain may be a contributory or exciting
cause of hysteria.
DISEASES OF THE CIRCULATORY SYSTEM AND
KIDNEYS.
Anemia, if severe, causes characteristic ophthalmic
changes. If a^ute. as from hemorrhage, the patient may
become suddenly blind, with ophthalmoscopic changes
(page 384), that later may go on to those of optic atrophy
(page 391), although at least partial recovery of sight is
the rule. Chronic simple anemia presents a pearly-white
sclerotic, and pallor of the inner surface of the lids. The
fund us of the eye appears pale throughout, the retinal
arteries are slightly narrowed. The retinal veins are pale
but very broad, with a broad light-streak (page 86).
I,eukemia and pernicious anemia may present the
appearance of simple anemia, with even greater pallor of
the fundus. In severe cases there exists generally the
characteristic retinitis or neuroretinitis with retinal
hemorrhages (page 363) ; lymphoid tumors of the lid and
orbit, and chloroma (page 476) are sometimes associated
with leukemia.
Diseases of the Heart. — Aortic regurgitation caus-
ing a sudden drop in the arterial pressure is liable to
cause pulsation of the retinal arteries (page 86). Similar
pulsation may be caused by syncope. It may also be
noticed in sudden overaction of the heart from excite-
ment, and rarely in exophthalmic goiter. Distention of
the right heart and the venous system may cause disten-
tion and tortuosity of the retinal veins (page 92). Endo-
carditis may give rise to embolism of the central retinal
artery. General edema due to heart disease, although
OCULAR SYMPTOMS OF DISEASE. 573
not especially liable to involve the eyelids, may be noticed
there upon rising in the morning.
Aneurysm of the aorta or innominate may give
rise to embolism of the retinal artery (page 374), and to
dilatation of the pupil and widening of the palpebral fis-
sure and exophthalmos- through irritation of the cervical
sympathetic. Aneurysm of the internal carotid may
cause palsies of ocular muscles (page 204) ; and if it burst
into the cavernous sinus, it causes pulsating exophthalmos
(page 472).
Renal-vascular Disease. — Albuminuric retinitis
(page 365) occurs chiefly when after a period of high
arterial tension the circulation begins to fail. The retinal
lesions are so directly connected with the vascular condi-
tion, and the retinal vessels are so largely affected in the
process, that it would belong more properly with circulatory
than with renal disorders. In some cases no albumin may
be found in the urine, and no symptoms of kidney disease
'may be noticed, but chronic advanced angiosclerosis is
always present. The kidney disease with which it
usually occurs is chronic interstitial nephritis, although
albuminuric retinitis may attend the large white kidney,
acute nephritis, or the albuminuria of pregnancy.
Retinal hemorrhage (page 360), so marked a feature
of albuminuric retinitis, may occur without other retinal
changes, and may be followed by hemorrhagic glaucoma
(page 444). Detachment of the retina (page 377) some-
times occurs, but retinal edema may be taken for a
limited detachment. Paralyses of ocular muscles occur
in rare cases, and the eye-muscles participate in eclampsia.
Uremie amaurosis (page 402) is sudden in its onset,
and usually complete, but the pupils continue to react to
light. Edema due to renal disease is often most notice-
able in the eyelids, but it may exist without affecting the
lids.
Albuminuric retinitis, retinal hemorrhage, and palsies of
the ocular muscles indicate an early fatal termination of
the disease. But few patients survive two years after
marked retinitis is noticed.
574 RENAL DISEASE.
Diabetes causes cataract which resembles other cat-
aracts in persons of similar age, except for a diffuse
clouding of the lens which may vary with the general
condition of the patient. Diabetics are sometimes sub-
ject to sudden and great changes in the refraction of the
eye, closely connected with changes in the amount of
sugar in the urine. Diabetic retinitis (page 368), although
rare, is a characteristic condition. Retinal hemorrhage
(page 360) is common. Central scotoma especially for red
and green, due to retrobulbar axial neuritis (page 391),
is met with ; and optic atrophy may follow. Palsies of
the ocular muscles or accommodation may occur, and
uveitis (page 314) may be due to diabetes.
'
DIATHETIC DISEASES.
Rheumatism. — The characteristics of rheumatic iritis
have already been described (page 319). Oyclitis may also
occur. A mild cyclitis probably more often than iritis
accompanies acute attacks of articular rheumatism. Ocu-
lar palsies (page 204) arise from rheumatic disease of the
nerve-trunks. But many cases loosely classed as rheu-
matic are, probably, simply neuritis from cold or other
non-rheumatic cause. Rheumatic endocarditis is a chief
cause of embolism of the central artery of the retina (page
374). Chronic rheumatic inflammation may affect the
sclero-corneal coat of the eye, causing scleritis, episcleritis
(page 311), or keratitis. Acute rheumatism may involve
the fibrous capsule of Tenon or the tendons of the ocular
muscles.
Gout. — Gouty inflammation of retina, optic nerve, and
choroid (page 368), although clinically distinct from both,
is closely allied to diabetic and albuminuric retinitis, and
of similar grave prognostic import. Iritis, due to gout
(page 319), is insidious and tends to relapses. Scleritis
(page 311) and brief periodic episcleritis (page 243) seem
to be associated with gout. Glaucoma, especially simple
glaucoma (page 443), occurs in persons of a gouty tend-
ency, and senile cataract has been ascribed to this diathe-
OCULAR SYMPTOMS OF DISEASE. 575
sis. A recurring hyperemia, or dry catarrh of the
conjunctiva, may be due to gout. Superficial painful
ulcer near the corneal margin occurring in old people
(page 286) and sclerotising keratitis are also regarded as
of gouty origin.
Purpura is often attended with retinal hemorrhage,
and hemorrhage may occur in the choroid, conjunctiva,
and lids, or in the depth of the orbit where it would
cause exophthalmos. Similar hemorrhage may occur in
Scurvy, although few cases have been reported.
Scrofula or strutna has largely been merged in
tuberculosis. But there are certain diseases of the eye
distinctly associated with a diathetic condition marked by
a pasty, inelastic, rough skin, liable to eczematous erup-
tions, a tendency to catarrhal inflammations of the mucous
membranes, disordered digestion, constipation, foul tongue,
and anemia. These diseases are : Marginal blepharitis
(page 449), phlyctenular conjunctivitis (page 261), and
keratitis, both phlyctenular and interstitial (pages 288
and 292).
CHRONIC INFECTIOUS DISEASES.
Tuberculosis of the eye is rare. It may involve the
iris (page 330), or the choroid (page 352), with distinct
characteristic tubercular deposits. It may aifect the con-
junctiva, causing an intractable inflammation and thick-
ening (page 268), or it may invade the lids, as lupus
(page 461). Tubercles in the choroid generally occur in
a late stage of general tuberculosis ; but the disease may
be primary, or, at least, antedate other manifest lesions.
Tubercular disease of the brain causes the same ocular
symptoms as other organic brain disease.
Syphilis. — The primary sore may occur on the lids
(page 453) ; or in the conjunctiva (page 268), especially on
the caruncle and on the palpebral portion. The secondary
eruption may involve the lids, or cause falling of the
lashes and eyebrows ; but the important secondary lesions
are those of the uveal tract. Iritis (page 319) may be
576 SYPHILIS.
the earliest of secondary symptoms, or one of the latest.
Cyclitis (page 324) is of much the same significance.
They yield well to specific treatment. Syphilitic chor-
oiditis, chorioretinitis (page 369), optic neuritis (page 385),
and dust-like opacity of the vitreous (page 427), are more
intractable.
Tertiary syphilis of the lids causes tarsitis (page 450),
and in both the lids and conjunctiva ulcers with thick-
ened margins that may be mistaken for cancer. A gumma
may occur in any part of the eye or its appendages. The
more important lesions of the kind affect the iris and the
ciliary body (page 330), the walls of the orbit (page 471),
and the lacrimal passages (page 466) Chorioretinitis
(page 369), retlnitis pigmentosa (page 372), optic neuritis
and atrophy are important manifestations in this stage.
Glaucoma (page 445) may arise in this stage. Palsies of
the ocular muscles (page 204) are most often due to tertiary
syphilis. Syphilitic disease of the central nervous sys-
tem, or of other organs of the body, may give rise to the
concomitant eye-affections.
Inherited syphilis is the cause of the majority of cases
of interstitial keratitis (page 292), and the accompanying
iritis, cyclitis, and choroiditis. It occasions most congen-
ital opacities of the cornea (page 301), and may cause cat-
aract and vitreous opacities. It may give rise to many
of the lesions of tertiary syphilis, and especially to reti-
nitis pigmentosa, and disease of the lacrimal passages.
The Hutchinson teeth and their significance are discussed
on page 295.
Gonorrhea, by local infection of the conjunctiva,
causes the great mass of cases of purulent conjunctivitis in
adults (page 243), and of the ophthalmia of the ne\v-
born (page 245), with their complications and sequels of
suppuration of the cornea (page 278), corneal leucoma
(page 301), and staphyloma (page 305), with permanent
blindness. It may also, either with or without gonor-
rheal rheumatism, cause a mild conjunctivitis apparently
without infection.
Iritis due to gonorrhea (page 319) may appear early,
OCULAR SYMPTOMS OF DISEASE. 577
apart from any rheumatic manifestations, or later with
joint involvement. In the former case it is very acute,
with excessive plastic exudation, but yields to treatment
and ends in good recovery. In the latter it is less vio-
lent, but shows a tendency to relapse, usually in connec-
tion with the relapse of the urethral discharge, and the
rheumatic symptoms.
I/eprosy causes destruction of the lashes and eyebrows,
anesthetic patches, and nodules in the lids ; and the result-
ing deformity of the lid may cause disease of the cornea,
pannus (page 298). The disease also invades directly the
conjunctiva and interior of the eyeball. The limbus is
especially the seat of nodules. Iritis and vitreous opac-
ity occur, or the eye may be lost through the corneal
anesthesia and neuroparalytic ophthalmia (page 287).
Malaria. — Persons who have suffered from malaria
are liable to certain forms of chronic keratitis (page 286),
and malarial neuralgias often involve the ophthalmic
branch of the trifacial nerve. Optic neuritis (page 385),
usually followed by partial atrophy, attends the tropical
malarias. Sudden anemia of the retina may occur and be
followed by optic atrophy. Retinal hemorrhages (page
360) occur, and effusions into the vitreous (page 429). A
transient retinochoroiditis has been described as due to
malaria. Sudden amaurosis, apart from the use of quinin,
has also been reported.
ACUTE INFECTIOUS DISEASES.
All these diseases may be attended in the acute febrile
stage by hyper emia of the conjunctiva (page 60), and pho-
tophobia connected with meningeal irritation.
Measles may begin as an acute catarrhal conjunctivitis
(page 237). Generally the conjunctiva participates in the
irritation of the mucous surfaces, there being conjuncti-
val hyperemia, photophobia, and increased lacrimation.
Toward the close of the disease and afterward, there
may remain a strong tendency to chronic conjunctivitis,
catarrhal (page 253) or phlyctenular (page 261), with a
37
578 MEASLES.
tendency to corneal ulceration (page 276). This condition
of lowered resisting power may last for many months.
Keratomalacia (page 287) has been observed. There may
also be a persistent asthenopia without obvious cause, or
excessive annoyance from low degrees of ametropia. Men-
ingitis may cause muscular palsies, optic neuritis, and
blindness.
Scarlatina, while less frequently attended with acute
catarrhal conjunctivitis than measles, is more liable to be
followed by serious corneal disease, and lacrimal disease,
inflammation of the gland (page 467), or obstruction of
the lacrimal passages. It is also liable to be followed by
orbital cellulitis (page 468), and the eye-complications of
meningitis. But the most important ocular lesions due to
scarlet fever are those of albuminuric retinitis (page 365)
and associated conditions.
Diphtheria may attack the conjunctiva, causing the
classical diphtheritic conjunctivitis (page 250), or less
violent conjunctival disease with destruction of the cornea.
More frequent is the diphtheritic paralysis of accommoda-
tion (page 333) which comes on after convalescence from
the throat-lesions has begun, and lasts several weeks.
Partial or complete palsies of the extra-ocular muscle (page
214) are not rare. They are seen later, sometimes many
months after the diphtheritic attack. Convergent squint
following diphtheria may be established by excessive
efforts during the period of weakened accommodation.
Influenza is followed by a period of nervous depres-
sion, during which paresis of accommodation (page 333) and
excessive asthenopia or fatigue from use of the eyes are
common. In a few cases it has been followed by narrow-
ing of the field of vision and optic atrophy (page 391).
The writer has seen lens-opacity rapidly increased by it.
It has been followed by orbital cellulitis (page 468).
Glaucoma has been ascribed to it.
Smallpox causes blindness through suppurating cor-
neal ulcer (page 278) which appears near the end of the
second week of the disease, never in the early stage.
Such ulcers may heal, however, without perforation. The
OCULAR SYMPTOMS OF DISEASE. 579
primary eruption rarely, or never affects the cornea ; but
it may appear on the conjunctiva and lids, and cause per-
manent deformity of the lid-margins or the lashes by the
scars.
Vaccinia occasionally affects the eyelids, causing great
swelling and induration with involvement of the related
lymphatic glands. One or more pustules form and run
the usual course. The conjunctiva at the height of the
disease may present a croupous deposit (page 250), but
the cornea escapes without serious injury. The scars
cause deformity of the lid or trichiasis. The disease is
generally due to direct inoculation ; but cases have been
reported in which the lid-lesions followed inoculation else-
where. Vaccination on the lids has been resorted to pur-
posely for the cure of nevus (page 461).
Chicken-pox may be followed by subacute catarrhal
conjunctivitis or simple corneal ulcer.
Whooping-COUgh, by the violent straining of the
coughing spells, causes hemorrhage which is most fre-
quently located under the ocular conjunctiva (page 270),
but which may occur in the lids or orbit, or so as to
involve the optic nerve, causing blindness by optic atrophy,
or may produce palsies through involvement of the motor
nerves.
Mumps may cause edema of the lids (page 459) and
chemosis through extension of the swelling from the
parotid ; or the lacrimal glands may be involved (page
457). Exophthalmos, optic neuritis, and consecutive
optic atrophy have been reported.
Cerebrospinal meningitis usually affects the eyes.
Conjunctivitis occurs in most cases. There may be edema
of conjunctiva and lids, and other evidences of venous
congestion. Thrombosis of the retinal vein (page 377),
and retinal hemorrhages, have been noted. The cornea is
often involved late in the disease. Plastic inflammation
of the iris and choroid, and purulent choroiditis (page 341)
and retinitis (page 362) leading to paeudo-gKoma, are very
important complications. Optic neuritis, tending to con-
secutive atrophy (page 391) if the patient survive, is not
580 CEREBROSPINAL MENINGITIS.
rare. Abnormalities of the pupil (page 72) are common,
and palsies of the extra-ocular muscles (page 204) occur.
Purulent inflammation commonly ends in blindness, and
plastic inflammation of the uveal tract may do the same.
Optic neuritis may be followed by recovery, usually par-
tial. Other conditions commonly end in recovery. A
large proportion of cases presenting severe lesions of the
eye do not survive the attack.
Erysipelas of the eyelids has already been described
(page 452). It is only when affecting the lids and ad-
joining parts that it is likely to involve the eye, unless it.
causes meningitis. If it extends into the orbit it may
cause retinal thrombosis (page 376), optic neuritis (page
384), or optic fitrophy (page 391). Its tendency to cause
glaucoma (page 438) has been frequently noted, but not
satisfactorily explained. It may cause inflammation of
the lacrimal gland (page 467) or of the lacrimal sac.
Pyemia, septicemia, and puerperal fever are liable
to involve the eye, causing either retinal hemorrhage
(page 360) and thrombosis, or purulent inflammation of
the choroid (page 341) or retina (page 362), and pseudo-
glioma, or panophthalmitis through septic embolism.
Typhoid fever may be attended with catarrhal con-
junctivitis (page 241), and is often succeeded by decided
weakness of accommodation (page 144). It may be compli-
cated by inflammation of the uveal tract ; and in rare cases
optic neuritis and subsequent atrophy occur. Typhus
may cause conjunctivitis and uveal inflammation. In the
typhoid state developing in any acute disease, the cornea'
is liable to suffer from exposure by imperfect closure of
the lids, to become dry and hazy, and later to ulcerate.
Relapsing fever is followed after some weeks by
uveal inflammation, especially cyclitis (page 324) and cho-
roiditis (page 344), attended with vitreous opacity. It
may end in recovery, or shrinking of the eye (page 350),
or panophthalmitis (page 341).
Cholera. — In this disease sinking of the eye and con-
traction of the retinal vessels, with a dark venous color
of the arteries, result from the general loss of fluid, and
OCULAR SYMPTOMS OF DISEASE. 581
the cornea is especially liable to suffer from exposure,
leading to keratitis if the patient survives.
Yellow fever begins with marked conjunct! val hyper-
emia (page 237) and lacrimation. Subsequently the
general yellow discoloration is added to the redness of
the conjunctiva. Subconjunctival hemorrliages (page 270)
and retinal hemorrhages (page 360) may occur.
CONDITIONS OF THE SEXUAL ORGANS.
Certain of the diseases of the eye show a distinct pre-
dilection for one sex rather than the other. Thus, spon-
taneous retinal hemorrhages occur in young men, and
idiopathic optic neuritis is more common in women.
Sexual excesses have seemed to cause optic atrophy
in men, quite apart from syphilis or other causes.
Menstruation exerts a marked influence on chronic
inflammatory disease, in some women, or upon the recur-
rence of conjunctivitis or scleritis. Disease of the uveal
tract with vitreous opacities is especially influenced by
it. Arrest of menstruation may be followed by hemor-
rhages, either subconjunctival or into the vitreous (page
429) or retina (page 360), and much hemorrhages may
occur at recurring menstrual epochs. Profuse uterine
hemorrhage may cause amaurosis.
Pregnancy may give rise to albuminurio retinitis
(page 365), which may be so severe as to justify prema-
ture labor to prevent blindness. When the question
arises, it is not merely a matter of blindness, since the
retinal lesion indicates very grave danger to the patient's
life and diminished chances of a living healthy child, even
if born at term. The prognosis for recovery from the
retinal lesions, after termination of the pregnancy, is
good as compared with other forms of albuminuric retin-
itis, if serious renal disease does not remain.
I/actation, if too prolonged, and seriously impairing
the mother's strength, may cause blindness by anemia of
the retina and subsequent optic atrophy. Slight abrasions
of the cornea may give rise to a very painful ulceration
582 LACTATION.
(page 286). The patient may also suffer from asthenopia
out of proportion to her ametropia, or the amount of eye-
work. Ocular disorders ascribed to the menopause are
more frequently due to failing accommodation (page 144).
DISEASES OF THE NOSE.
The intimate relations of the eyes with the nose are
illustrated by such common reflexes as the provocation
of sneezing by the flashing of a bright light in the eyes,
or the free lacrimation produced by any irritation of the
nasal mucous membrane.
Acute cory^a is commonly attended with conjuncti-
val hyperemi»and increased lacrimation, which frequently
passes into an acute catarrhal conjunctivitis (page 237) or
a blepharitis (page 449).
Catarrhal rhinitis of the form compared to eczema
of the skin, and frequently coexistent with eczema, is a
common cause of relapsing phlyctenular conjunctivitis
(page 261) or phlyctenular keratitis (page 268). Its cure
may be essential to prevent further relapses.
Hypertrophic rhinitis may, by pressure, close the
lower end of the lacrimo-nasal duct, causing lacrimal
obstruction (page 465) with all its consequences. Cica-
tricial contraction after severe acute rhinitis or atrophic
rhinitis may do the same thing. Chronic inflammations
within the nose are liable to extend to the lacrimal
duct and sac, and produce obstruction by swelling of the
lining membrane. Caries and necrosis of the adjoining
bones, cause some of the most obstinate and hopeless
cases of lacrimal obstruction.
Polypoid growths are probably a cause of optic
atrophy. A form of atrophy (page 393) associated with
dropping of watery fluid from the nostril, and associated
with the presence of polypi, has been reported. The
damaging pressure is doubtless exerted in the sphenoidal
sinuses. Such growths have also seemed to cause stra-
bismus.
Active treatment of nasal disease, especially by the
OCULAR SYMPTOMS OF DISEASE. 583
galvano-cautery, has caused temporary amblyopia and
even optic neuritis.
Diseases of cavities accessory to the nose
(the frontal, maxillary, ethmoid, and sphenoid sinuses)
cause caries or necrosis of the orbital walls (page 470),
orbital abscess (page 468), orbital exostosis (page 476),
exophthalmos (page 465), palsies of ocular muscles (page
204), optic neuritis (page 384), and optic atrophy (page
391). Such effects are usually caused by empyema of
these cavities, but may be due to mucocele. Such disease
may also cause headaches, which, on account of their
location, are likely to be ascribed to eye-strain.
POISONS.
The effects of drugs upon the eye have been elsewhere
set forth, under mydriatics (page 127) or myotics (page
129) and the toxic amblyopias (page 397). Mydriatics
may produce decided visual hallucinations. These are
also very striking in poisoning by Indian hemp and
the mescal button. Myosis (page 76) is one of the
effects of poisoning by opium, chloral, and muscarin.
Paresis of the ocular muscles and squint with diplopia
may be produced by alcohol, gelsemium, and to a less
extent by other narcotics. Yellow vision, preceded by
brief violet vision, is one of the most striking symptoms
of poisoning by santonin.
BIBLIOGRAPHY.
In addition to those mentioned in the preface to the first edition, the
following publications, all in the English language, will be found most
helpful by the student who desires to extend his studies beyond the
limits of the present volume.
GENEKAL WOKKS.
Pathology of the Eye. J. Herbert Parsons. Two vols., 1905.
The Eye and Nervous System. Their Diagnostic Relations. By
Various Authors. Edited by W. C. Posey and W. G. Spiller, 1906.
The Fundus Oculi, with an Ophthalmoscopic Atlas. W. Adams Frost,
1896.
Text-book of Ophthalmoscopy. Two vols., E. G. Loring, 1891.
Diseases of the Eye. Fifth edition. G. E. deSchweinitz, 1906.
Text Book of Ophthalmology. E. Fuchs. Translated by A. Duane.
Modern Ophthalmology. J. M. Ball, 1904.
The Eye. Its Refraction and Diseases. E. E. Gibbons. Two vols.,
1905.
On Becoming Blind. E. Javal. Translated by C. E. Edson, 1905.
ANNUAL AND OCCASIONAL PUBLICATIONS.
The Ophthalmic Year-book. Edited by Edward Jackson and G. E.
deSchweinitz. Since 1904. Including list of all ophthalmic
publications.
Practical Medicine Series of Year Books. Diseases of the Eye.
Edited by Casey A. Wood. Since 1901.
Progressive Medicine. June volumes since 1899.
American Year Book of Medicine and Surgery. Volume on Surgery.
Since 1896.
Transactions of International Ophthalmological Congresses. Tenth,
1904.
Transactions American Ophthalmological Society. Ten vols. since
1865.
Transactions of the Ophthalmological Society of the United Kingdom.
Twenty-five volumes since 1881.
Transactions of the Section on Ophthalmology of the A. M. A. Fifteen
volumes since 1891.
Transactions of the American Academy of Ophthalmology and Oto-
Laryngology since 1896.
Royal London Ophthalmic Hospital Reports. Sixteen volumes.
Issued in parts.
New York Eye and Ear Infirmary Reports. One part each year since
1893.
585
586 BIBLIOGRAPHY.
MONOGRAPHS AND JOURNAL ARTICLES.
EXAMINATION OF VISION.
Principle of Test Type Construction. B. A. Randall, " Anier. Jour.
of Ophth.," July, 1905.
Determination of Acuteness of Vision and Graduation of Optotypes.
John Green, " Trans. Amer. Ophth. Soc.," 1905.
Studies in the Light Sense. P. J. Hay, " Arch, of Ophth.," March,
1905.
Bjerrum's Method of Testing Field of Vision. A. H. H. Sinclair,
" Trans. Ophth. Soc. of United Kingdom," vol. xxv.
Recent Improvements in Perimetry. F. A. Davis, " Ophth. Record,"
May. 1906.
Color Vision and Color Blindness. Second Edition. J. E. Jennings.
EXTERNAL EXAMINATION OF THE EYE.
Atlas of the External Diseases of the Eye. O. Haab. Edited by
G. E. deSchweinitz.
Transillumination of the Sclera. H. R. Swanzy, " Ophth. Review,"
Feb., 1905.
Measurement of Prominence of Eyeball. Edward Jackson, " Amer.
Jour, of Med. Sciences," July, 1903.
OPHTHALMOSCOPIC EXAMINATION.
Atlas and Epitome of Ophthalmoscopy and Ophthalmoscopic Diagnosis.
O. Haab. Edited by G. E. deSchweinitz, 1901.
The Ophthalmoscope and How to Use It. James Thorington, 1906.
Ophthalmoscopic Examination of the Macula. Edward Jackson,
"Ophth. Record.," June, 1903.
Blood Vessels of the Optic Disk in Some Lower Animals. E. Nettle-
ship, " Trans. Ophth. Soc. of United Kingdom," vol. xxv.
The Ocular Fundus as Seen by the Mercury Vapor Lamp. M. S. Mayou,
" Lancet," March, 1903.
GENERAL REFRACTION OF THE EYE.
Anomalies of Accommodation and Refraction of the Eye. F. C. Don-
ders, 1864.
The Refraction and Accommodation of the Eye and Their Anomalies.
E. Landolt. Translation by C. M; Culver, 1886.
The Refraction of the Eye. Thirteenth Edition. G. Hartridge.
Refraction and Plow to Refract. Third Edition. James Thorington.
Refraction and Motility of the Eye. W. N. Souter.
Skiascopy and Its Practical Application. Fourth edition. E. Jackson.
Photoscopy (Skiascopy or Retinoscopy). M. D. Stevenson.
BIBLIOGRAPHY. 587
ACCOMMODATION AND CYCLOPLEGICS.
Further Investigations on Accommodation. K. Grossmann, " Ophth.
Review," December, 1904.
Mechanism of Accommodation and Astigmic Accommodation. E. Jack-
son, " Trans. Amer. Acad. of Ophth. and Oto-Laryngology," 1905.
Apparent Power of Accommodation with Ectopia Lentis. J. W. Charles,
"Amer. Jour, of Ophth.," May, 1905.
Strength of the Different Mydriatics and Myotics. E. Jackson,
" Trans. Sec. on Ophth., Amer. Med. Assn.," 1895.
ERRORS OF REFRACTION AND LENSES.
Myopia. Priestley Smith, " Ophth. Review," December, 1901.
Removal of the Crystalline Lens in High Degrees of Myopia. S. Snell,
" Brit. Med. Jour.," Feb. 27, 1904:
Practical and Theoretical Treatise on Astigmatism. S. M. Burnett, 1887.
Effects of Lid Pressure on the Cornea. G. J. Bull, "Trans. Eighth
International Ophthalmic Congress," Edinburgh, 1893.
The Symmetrical Aberration of the Eye. E. Jackson, " Trans. Amer.
Ophth. Soc.," 1888.
Anisometropia. A. Duane, "Arch, of Ophth.," Nov., 1901.
Spectacles and Eye-glasses. Their Forms, Mounting and Proper
Adjustment. R. J. Phillips.
Biographic Clinics. Three vols. G. M. Gould.
DISORDERS OF OCULAR MOVEMENTS.
The Muscles of the Eye. Lucien Howe.
Tests and Studies of the Ocular Muscles. Also the Clinical Use of
Prisms. E. E. Maddox.
Squint : Its Causes, Pathology and Treatment. Second edition.
C. Worth.
Ophthalmic Neuro-Myology. G. C. Savage.
Strabismus or Squint, Latent and Fixed. F. Valk.
Types of Eye Movement. R. Dodge, " Amer. Jour, of Physiol." Jan.,
1903.
Paralysis of Convergence. A. Duane, "Ophthalmology," Oct., 1906.
Deficiency of Adduction and Abduction. Retraction Movement and
Contraction of Palpebral Fissure. A. Duane, " Arch, of Ophth.,"
March, 1905.
Nystagmus. A. Duane, " Arch, of Ophth.," Sept., 1905.
Stereoscopic Exercises with Series of Pictures. A. B. Hale, " Jour.
Amer. Med. Assn.," Oct. 10, 1903.
Spasmus Nutans. M. Buchanan, " Ann. of Ophth.," July, 1905.
DISEASES OF THE CONJUNCTIVA.
The Conjunctiva in Health and Disease." N. B. Harman.
Bacteriology of the Conjunctiva. W. B. I. Pollock, "Trans. Ophth.
Soc. of United Kingdom," vol., xxv.
BIBLIOGRAPHY.
Bacterial Types of Acute Conjunctivitis. A. Duane, " Trans. Amer.
Ophth. Soc.," 1905.
Clinical Importance of the Diplobacillus of Morax and Axenfeld.
H. Gifibrd, " Ophth. Record," Nov., 1905.
Conjunctivitis Nodosa with Histological Examination. G. E. de-
Schweinitz and E. A. Shumway, "Trans. Amer. Ophth. Soc.,"
vol. x.
Fatal Septicemia Due to Ophthalmia Neonatorum. E. W. Stevens,
" Ophth. Record," Nov., 1905.
Treatment of Purulent Conjunctivitis. M. Standish, " Trans. Sec. on
Ophth., Amer. Med. Assn.," 1904.
Parinaud's Conjunctivitis. C. N. Spratt, " Arch, of Ophth.," March-
May, 1906.
Vernal Conjunctivitis. W. C. Posey, " Jour. Amer. Med. Assn.,"
July 25, 1903.
The Ophthalmic History of an English School. Sydney Stephenson,
"Arch, of Ophth.," July, 1900.
Pinguecula and Ftervgium. A. Alt, " Amer. Jour, of Ophth.," July,
1905.
Pemphigus of the Conjunctiva. W. B. Marple, "New York Eye and
Ear Infirmary Rep.," 1900.
Conjunctivitis Petrificans. W. C. Posey, "Ann. of Ophth.," April, 1905.
Tumors of the Conjunctiva. E. A. Shumway, " Jour. Amer. Med.
Assn.," Sept. 26, 1903.
DISEASES OF THE CORNEA AND SCLERA.
Corneal Epithelium in Repair of Ulcers E. Fuchs, ''Trans. Ophth.
Soc. of United Kingdom," June 13, 1902.
Quinine for Comeal Ulcers. A. Lawson, " Trans. Ophth. Soc. of United
Kingdom," vol. xxv.
Serpent Ulcer of the Cornea caused by the Pneumococcus. H. Gifford,
"Arch, of Ophth.," March, 1898.
Suppurating Ulcer of the Cornea. C. J. Kipp, "Jour. Amer. Med.
Assn.," Aug. 9, 1902.
Chronic Creeping Ulcer of the Cornea. E. Nettleship, " Trans. Ophth.
Soc. of United Kingdom," Nov. 8, 1901.
Dendritic Keratitis. J. W. Charles, " Amer. Jour, of Ophth.," April,
1904.
Aspergillus Keratitis. J. M. Ball, " Amer. Med.," July 6, 1901.
Trophic Keratitis. G. C. Harlan, " Trans. Amer. Ophth. Soc.," 1897.
Is Keratitis Ever caused by Rheumatism? L. Connor, "Ophthal-
mology," July, 1905.
Chancre of the Eye Lid with Interstitial Keratitis. J. T. Carpenter,
"Ophth. Record," Dec., 1905.
Corneal Lesions of Acquired Syphilis. S. Stephenson, "Ophthalmo-
scope," November, 1903.
Family Degeneration of the Cornea. R. W. Dovne and S. Stephenson,
"Ophthalmoscope," May, 1905.
Corneal Cysts. E. L. Oatman, " Arch, of Ophth.," May, I'.tiU.
Episclei'itis and Scleritis. A. Alt, "Amer. Jour, of Ophth.," April,
1903.
BIBLIOGRAPHY. 589
DISEASES OF THE UVEAL TRACT.
Uveitis. G. E. deSchweinitz, Hiram Woods, Harry Friedenwald,
Howard F. Hansell, W. H. Wilder, T. A. Woodrufl; W. B. Marple.
Reprint from "Jour. Amer. Med. Assn.," 1902.
Recurrent Iritis. H. Woods, " Trans. Amer. Ophth. Soc.," 1905.
Iritis with Bright's Disease. A. Alt, "Amer. Jour, of Ophth.," July,
1905.
Tubercular Iritis Diagnosed and Treated by Tuberculin. W. E. Gamble
and E. V. L. Brown, "Jour. Amer. Med. Assn.," Oct. 14, 1905.
Cysts of Posterior Surface of Iris. E. L. Oatman, " Arch, of Ophth.,"
May, 1905.
Sarcoma of the Ciliary Body and Iris. C. A. Wood and Brown Pusey,
" Arch, of Ophth.," July, 1902.
Paralysis and Paresis of the Muscle of Accommodation. G. F. Suker,
" Amer. Jour, of Ophth.," July and August, 1903.
Theories of Sympathetic Ophthalmia. H. Gifford, " Arch, of Ophth.,"
Nov., 1902.
Sympathetic Inflammation Following Panophthalmitis. W. Zentmayer,
"Jour. Amer. Med. Assn.," Aug. 19, 1905.
Metastatic Choroiditis. C. S. Bull, "Trans. Amer. Ophth. Soc.," 1901.
Meningitis Following Excision of the Eye Ball. C. D. Marshall,
" Ophthalmoscope," Dec., 1905.
Central Superficial Choroiditis. T. B. Schneidetnan, " Amer. Jour, of
Ophth.," Jan., 1905.
The Choroidal Arteries a Factor in the Localization of Choroiditis and
Retinitis. E. Nettleship, " Royal London Ophth. Hospital Rep.,"
xv, 3, 1903.
Tubercle of the Choroid. G. Carpenter and S. Stephenson, " Ophthalmo-
scope," August, 1905.
Prognosis of Tveal Sarcoma. C. D. Marshall, " Royal London Ophth.
Hospital Rep.," xv, 1.
Metastatic Carcinoma of the Choroid. E. L. Oatman, " Amer. Jour.
of Med. Sciences," March, 1903.
DISEASES OF THE RETINA.
Renal Retinitis. E. Nettleship, " Royal. London Ophth. Hospital
Rep.," xv, 4.
Renal ' Retinitis in Young Subjects. E. Nettleship, " Royal London
Ophth. Hospital Rep.," xvi, 1. . . .
Duration of Life after Appearance of Albuminunc Retinitis. >. Smell,
"Lancet," July 15, 1905.
Ophthalmic Changes in Chlorosis, Pernicious Anemia, and Leucocy-
themia. C. A. Oliver, " Trans. Amer. Ophth. Soc., J 897.
Pigmentary Degeneration of the Retina. W. L. Pyle, "Trans. Amer.
Ophth. Soc.," 1903. „
New Formed Vessels in the Retina. S. M. Burnett, " Ophth. Record,
Dec., 1899.
Ophthalmoscopic Evidence of General Arterial Disease. Marcus Gunn,
" Trans. Ophth. Soc. of United Kingdom," March, li>98.
590 BIBLIOGRAPHY.
Obstruction of the Retinal Circulation. A. H. Thompson, "Ophth.
Review," March-April, 1902.
Treatment of Recent Embolism of Retinal Arteries by Digital Massage.
H. V. Wiirdemann, " Trans. Amer. Acad. of Ophth. and Oto-
Laryngology," 1905.
Cyanosis Retinae. W. C. Posey, " Jour. Amer. Med. Assn.," Sept., 1905.
Treatment of Detachment of the Retina. W. B. Marple, " New York
Eye and Ear Infirmary Rep.," 1 904.
Pseudoglioma : Cystic Changes in the Retina. G. E. deSchweinitz and
E. A. Shumway, " Trans. Amer. Ophth. Soc.," 1901.
DISEASES OF THE OPTIC NERVE AND TRACTS.
Optic Neuritis in Cerebral Tumors. Subsidence after Operation. L.
Paton, " Trans. Ophth. Soc. of United Kingdom," xxv.
Retrobulbar Optic Neuritis. E. Nettleship, " Royal London Ophth.
Hospital Rep*," vol. xv, 1.
Hereditary Retrobulbar Neuritis. H. F. Hansell, " Trans. Amer. Ophth.
Soc.," 1900.
Gumma of the Optic Nerve. A. Alt, "Amer. Jour, of Ophth.," Julv,
1905.
Tumors of the Optic Nerve. W. G. M. Byers, " Studies from the Royal
Victoria Hospital," Montreal, Aug., 1901.
Ocular Symptoms of Lesions of the Optic Chiasm. G. E. deSchweinitz
and J. T. Carpenter, "Trans. Sec. on Ophth., Amer. Med. Assn.,"
1904.
Architecture of the Cerebral Apparatus. W. E. Gamble, "Ann. of
Ophth.," April, 1904.
The Arris and Gale Lectures on the Neurology of Vision. J. H. Par-
sons.
Binocular and Stereoscopic Vision, Decussation of the Optic Nerve,
Ocular Movements, Pupil and Light Reflex. W. Harris, " Brain,"
xxvii, No. 15, 1904.
AMBLYOPIAS.
Toxic Amblyopias. G. E. deSchweinitz.
Toxic Amblyopias. Casey A. Wood.
Tobacco Amblyopia : Analysis of Urine. G. E. deSchweinitz and D. L.
Edsall, "Trans. Amer." Ophth. Soc.," 1903.
Poisoning by Wood Alcohol. C. A. Wood and F. Buller, " Trans.
Sec. on Ophth., Amer. Med. Assn.," 1904.
Scintillating Scotoma. Transient Functional Hemianopsia. C. J.
Kipp, "Jour. Amer. Med. Assn.," April 22. 1905.
New Tests for Simulated Monocular Blindness. Edward Jackson,
" Phila. Med. Jour.," April, 16, 1898.
Congenital Word Blindness. J. Hinshelwood. " Ophthalmoscope," Oct.,
1904.
BIBLIOGRAPHY. 591
DISEASES OP THE VITREOUS AND LENS.
Heredity in Various Forms of Cataract. E. Nettleship, " Royal Lon-
don Ophth. Hospital Rep.," xvi, 3 and 4.
Association of Cataract with Uncinariasis. A. W. Calhoun, " Ophth.
Record," April, 1904.
Regeneration of the Crystalline Lens. R. L. Randolph, " Johns Hop-
kins Hospital Rep.," vol. ix.
Coralliform Cataract. J. H. Fisher, " Trans. Ophth. Soc. of United
Kingdom," xxv.
Extraction of Immature Senile Cataract. A. E. Bulson, Jr., " Jour.
Amer. Med. Assn.," Sept. 23, 1905.
Reclination of the Lens. F. T. Rogers, "Jour. Amer. Med. Assn.,"
April, 22, 1905.
Spontaneous Hemorrhage into the Vitreous. T. B. Schneideman,
"Trans. Amer. Acad. of Ophth. and Oto-Laryngology," 1905.
Vascular Growths in the Vitreous. W. B. Marple, "Trans. Amer.
Ophth. Soc.," 1901.
Persistent Remains of the Fetal Hyaloid Artery. D. DeBeck, 1890.
DISORDERS OF TENSION OF EYEBALL.
Pathology and Treatment of Glaucoma. Priestley Smith.
Glaucoma. Its Symptoms, Varieties, Pathology and Treatment. A.
W. Stirling.
Glaucoma and the Influence of Mydriatics and Myotics. Edward
Jackson, " Amer. Jour. Med. Sciences," April, 1898.
The Field of Vision in Glaucoma. G. E. deSchweinitz, "Ann. of
Ophth.," 1899.
Iridectomy for Simple Glaucoma. C. S. Bull, " Trans. Amer. Ophth.
Soc.," 1902.
Physiology of the Sympathetic in Relation to the Eye. G. E. de-
Schweinitz, W. H. Wilder, J. M. Ball and J. E. Weeks, 1904.
DISEASES OF THE LIDS.
Blastomycosis of Eye Lid. W. H. Wilder, " Jour. Amer. Med. Assn.,"
Dec., 31, 1904.
Chancre of the Eye Lids. David De Beck.
Pediculi Ciliaris. P. N. K. Schwenk, " Wills Eye Hospital Rep.,"
1895.
Ophthalmic Herpes. W. C. Bane, "Jour. Amer. Med. Assn.," Dec.,
21, 1901.
Associated Movements of the Eye-lid and Jaw. G. C. Harlan,
"Ophthalmoscope," May, 1904.
Emphysema of Lids. T. R." Pooley, " Arch, of Ophth.," Jan., 1901.
Lymphoid Infiltration of Lids. E. Nettleship, " Royal London Ophth.
Hospital Rep.," May, 1902.
Trichiasis and Operations for Trichiasis. W. E. Cant, "Trans. Ophth.
Soc. of United Kingdom," vol. xxiv.
592 BIBLIOGRAPHY.
LACRIMAL DISEASE.
Chronic Enlargement of Lacrymal and Salivary Glands. Wm. Osier,
" Amer. Jour. Med. Sciences," Jan., 1898.
Bilateral Enlargement of the Lacrimal Glands. \V. T. Shoemaker,
"Ann. of Ophth.," July, 1904.
Traumatic Dislocation of the Lacrimal Gland with Foreign Body in
the Orbit. E. Jackson, "Ophth. Record," August, 1904.
Use and Abuse of the Lacrimal Probe. G. F. Suker, " Amer. Jour, of
Ophth.," Sept., 1904.
Extirpation of the Lacrimal Sac. A. Knapp, " Arch, of Ophth.." July,
1903.
DISEASES OP THE ORBIT.
Mechanism of Enophthalmos. W. T. Shoemaker, " Ann. of Ophth.,"
July, 1900.
Intermittent Exophthalmos. W. C. Posey, " Jour. Amer. Med. Assn.,"
Feb. 18, 190o.
Pulsating Exophthalmos. H. F. Hansell, "Jour. Amer. Med. Assn.,"
Feb. 18, 1905.
Treatment of Malignant Disease of Orbit by X-Ray. C. S. Bull,
"Trans. Amer. Ophth. Soc.," 1905.
Anophthalmos. J. H. Claibome, "Trans. Amer. Ophth. Soc.," 1901.
INJURIES TO THE EYE AND RELATED PARTS.
Hemorrhage in the Eye Present at Birth. F. B. Coburn, " Arch, of
Ophth.," May, 1904.
Late Results of Birth Injury to Cornea. L. Buchanan, " Trans. Ophth.
Soc. of United Kingdom," xxv.
Blasting Eye Injuries. J. A. Donovan, " Jour. Amer. Med. Assn.,"
Aug. 15, 1905.
Foreign Bodies Retained in the Cornea. E. Jackson, "Brit. Mr.l.
Jour.," Jan. 8, 1898.
Injuries to the Eye from Particles of Analine Copying Pencil. J. M.
Ray, " Ophthalmology," Oct., 1905.
Method" of Localizing Foreign Bodies in the Orbit. V. H. Hulen,
"Jour. Amer. Med. Assn.," April 2, 1904.
Methods for Localizing Foreign Bodies in the Eye by Roentgen Rays.
J. E. Weeks, "Trans. Amer. Ophth. Soc.," 1905.
Metallic Foreign Bodies within the Eye a.nd Their Removal. G. E. de-
Schweinitz, " Amer. Jour, of Ophth.," April, 1905.
Magnet Extraction. A. Haab, " Jour. Amer. Med. Assn.," Aug. 30,
1902.
Practical Remarks on Magnet Operations. J. FTirschberg, "Ophthal-
moscope," Feb., 1905.
Orbital Traumatism Causing Monocular Blindness. P. A. Callan,
" New York Eye and Ear Infirmary Rep.," 1893.
Blindness and Oculo-motor Palsies from Injuries not Involving the
Optic or Oculo-motor Nerves. A. A. Hubbell, " Trans. Sec. on
Ophth., Amer. Med. Assn.," 1904.
BIBLIOGRAPHY. 593
Expert Testimony as it Relates to Ophthalmology. D. T. Vail,
" Amer. Jour, of Ophth.," Sept., 1905.
Ocular Injuries, Pensions and Insurance Eates Estimation of Loss of
Earning Ability. H. V. Wiirdemann, " Ophthalmology," Jan.,
1905.
REMEDIES AND THEIR APPLICATIONS.
Ocular Therapeutics. A. Darier and S. Stephenson, 1903.
Ophthalmological Therapeutics. Landolt and Gygax.
The Treatment of Diseases of the Eye. V. Hanke. Translated by J.
H. Parsons and Geo. Coats.
Ocular Therapeutics. F. W. M. Ohlemann. Edited by C. A. Oliver.
Subconjunctival Salt Injections. S. D. Risley, "Jour. Amer. Med.
Assn.," August 12, 1905.
Electro-cautery for Corneal Wounds and Ulcers. J. A. Donovan,
" Amer. Jour, of Ophth.," Oct., 1903.
Conical Cornea, and Hot Air Cautery. K. Grossmann, " Brit. Med.
Jour.," Aug. 26, 1905.
Diaphoresis in Ophthalmic Therapeutics. H. Woods, " Jour. Amer.
Med. Assn.," Dec., 24, 1904.
Salicylate of Sodium in Large Doses in Inflammatory Eye Diseases.
H. Gradle, " Ophth. Record," Feb., 1903.
Infiltration Anesthesia. H. V. Wiirdemann, " Trans. Sec. on Ophth.,
Amer. Med. Assn.," 1895.
Stovaine : The New Local Anesthetic. S. Stephenson, " Ophthalmo-
scope," Nov., 1904.
Alypin: A New Local Anesthetic. S. Stephenson, " Ophthalmoscope,"
Nov., 1905.
Use of Thiosinamin. G. F. Suker, " Jour. Amer. Med. Assn.," Aug. 9,
1902.
Dionin. A. Darier, " Ophthalmoscope," March, 1904.
OPERATIONS.
Atlas and Epitome of Operative Ophthalmology. O. Haab. Edited
by G. E. deSchweinitz.
Ophthalmic Operations as Practiced on Animals' Eyes. C. A. Veasey.
Mental Derangement with Eye Operations. C. J. Kipp, " Arch, of
Ophth.," July, 1903.
Evolution in Blepharoplasty. A. H. Benson. "Brit. Me.d- Jour.,"
Aug. 26, 1905.
Operations for Entropion of Lower Lid. J. M. Ball, " Ann. of Ophth.,"
Jan., 1905.
Modification of Panas' Operation for Ptosis. F. Allport, " Jour. Amer.
Med. Assn.," April 11, 1903.
Operation of Motais. H. D. Bruns, " New Orleans Med. Jour.," June,
1905.
Treatment of Ptosis by Partial Resection of Tarsal Cartilage. E.
Gruening, " New York Eye and Ear Infirmary Rep.," 1904.
38
594 BIBLIOGRAPHY.
Transplantation of Pterygium. J. O. McReynolds, " Ophth. Record,"
May, 1901.
Technique of Implanting Thiersch Grafts for Syrablepharon. F. C.
Hotz, " Annals of Ophth.," July, 1905.
Division and Fixation of Flaps for Cicatricial Entropion. F. C. Ilotz,
" Amer. Jour, of Ophth.," June, 1903.
Advancement Operations. H. W. Wootton, " Arch, of Ophth.," May,
1901.
He-adjustment of Superior Rectus for Paresis of Superior Oblique. E.
Jackson, " Ophth. Review," March, 1903.
Lateral Displacement of Tendon Insertions for Strabismus. E. Jack-
son, "Jour. Amer. Med. Assn.," Aug. 19, 1905.
Conjunctival Covering of Operative Wounds Opening the Anterior
Chamber. E. C. Ellett, " Ophth. Record," April, 1903.
Extraction of Cataract in the Capsule. H. Smith, " Brit. Med. Jour.,"
Sept., 26, 1903.
Cataract with Small Peripheral Button-hole in Iris. H. B. Chandler,
"Arch, of Qphth.," Jan., 1904.
Lens Extraction with Conjunctival Flap. F. M. Wilson and H. S.
Miles, " Trans. Amer. Ophth. Soc.," 1902.
Intracapsular Irrigation in Cataract Operations. H. O. Reik, " Ann.
of Ophth.," July, 1903.
Reclination of the Lens under Certain Conditions a Justifiable Opera-
tion. F. T. Rogers, " Trans. Sec. on Ophth., Amer. Med. Assn.,"
1904.
Knife Needle Operation for Secondary Cataract. Edward Jackson,
"Arch, of Ophth.," March-May, 1906.
Artificial Eye-balls. H. Snellen, " Ophth. Review," Dec., 1898.
Motility and Position of the Artificial Eye after Enucleation. Priest-
ley Smith, " Ophth. Review," May, 1899.
Removal of Eyeball, Conjunctival Sac, and Lid Margins. A. Alt,
"Amer. Jour, of Ophth.," March, 1903.
Operation for Providing Cul-de-sacs for the Lodgment of Artificial
Eye. J. E. Weeks, " Trans. Tenth Internal. Congress of Ophth."
INDEX.
ABADIE, Ch.,441
Abbreviations, 23, 434
Abduction, 193, 231
congenital defect of, with retrac-
tion of eyeball, '23.")
Aberration, 186, 310, 410
Ablepharia, 448
Abrasion of cornea, 299, 487
Abscess of cornea, 278. 290, 291. 547
ring-, 274
of lids, 450
of orbit, 468
Abscission, 548
Absolute hyperopia, 149
scotoma, 39
Accommodation, 124, 132, 149, 152,
341
amplitude of, 126, 146
effect of, 125
spasm of, 149
weakness of, 41, 144, 164, 332, 341
Acetanilid, 402, 511
Aching, 52, 53, 239
Achromatopsia. See Color-blindness.
Actual cautery, 283, 547
Acuteness of vision, 18, 20, 21, 25,
569
Adaptation to glasses, 190
Adduction, 193, 231
Adenoma, 353
Adherent leucoma, 70, 301, 304, 446
Adhesion of lids, 6«. 238, 455
Adjoining cavities, 583
sinuses, diseases of, 476
Adrenal extract, 520, 529
Adrenalin, 520
Advancement, muscular, 214, 222,
234, 544
After-treatment of cataract, 556
of enucleation, 583
Age, changes of glasses with, 190
of patient, 18, 21, 26, 146, 221
Air-bubbles in vitreous, 497
Akromegaly, 570
Albinism, 88, 355
Albuminuric retinitis, 91, 365, 573,
578, 58 i
Alcohol amblyopia, 399"
Alexia, developmental, 406
Allen, Harrison, 295
Allport, F., 593
Alt, A., 588, 589, 590, 594
Altitudiual hemianopsia, 37
Alum, 512
Alypin, 515
Amaurosis, 402, 573
Amaurotic family idiocy, 374
Amber yellow glass, 501
Amblyopia. 198, 397, 402
central, 40, 397
congenital, 403
ex abusa, 397, 399
ex auopsia, 198
from acetanilid, 402
from alcohol, 399
from carbon bisulphid, 400
from iodoform, 400
from nitrobenzol, 400
from quinin, 401
from tobacco, 397
hysterical, 403
simulated, 403
sympathetic, 334, 341
toxic, 397
uremic, 365, 573
with squint, 198
Amblyoscope of Worth, 221
Arnetropia, 19. 124, 134, 267, 411
Amplitude of accommodation, 126,
146
Amyloid degeneration of conjunc-
tiva, 269
Anchyloblepharon. 458
Anemia, 359. 363, 383, 572
of optic disk, 96, 3S4
of retina, 93, 359, 577
j Anesthesia of cornea, 54, 287, 436
I Anesthetics, 514
595
596
ISDEX.
Aneurism, 473, 567, 573
Angioid streaks in retina, 374
Angionia, 271, 460, 474
Angle of anterior chamber, 439
of deviation, 111
of vision, 25
Aniline dyes, 67, 510
Aniridia, 354
Auisometropia, 188
Annular syuechia, 327
Anomalies of choroid, 103
of iris and choroid, 353
of lids, 448
of inacular region, 382
of optic disk, 98
of pigmentation, 356
of refraction, 124
of retina, 381
of retinal vessels, 382
Anopthhalnios, 175
Anterior chamber, 407, 425, 547
foreign body in, 495
sclerotomy, 441, 549
staphyloma, 305, 548
symblepharon, 270
synechia, 71, 293, 301, 304
Autimetropia, 188
Antipathy to single vision, 220
Antiseptics, 507, 523
Antitoxin, diphtheria, 252
Antrnm, maxillary, 476
Apex of prism, 106
Aphakia, 407, 417, 426
Apoplexy, 567, 568
Apparent movement, 137
squint, 199, 219
Application of remedies, 500
Applications to conjunctiva, 504,
509, 520
Aqueous humor. 407
Arcus senilis, 70, 301
Argyll -Robertson pupil, 74, 569
Argyria, 273
Artryrol, 510
Aristol, 511
Arsenic, 511
Arterial pulsation, 437
Artificial eye, 564
leech, 529
Asepsis, 246, 505, 507, 523
Associated movements, 205
Assorted light, 104, 121
Asthenopia, 144, 151, 157, 174, 206,
227, 435, 578, 582
Astigmatic lens, 184
Astigmatism, 46, 167, 169
Astigmatism, changes in, 186
diagnosis, 171, 176', 178, IbO
irregular, ]6?
regular, 267, 169
treatment, 184, 188
varieties of, 169, 172
Astiginia, 167
Astringents, 506, 511
Atresia of punctum, 463
Atrophy of eyeball, 350
of iris, 329
of optic nerve, 98, 391, 398, 567
of retina, 361
retinal macula r, 374
Atropiu, 127, 238, 277, 289, 296, 322,
516, 517, 518, 519
Auramiu, 510
Auto-iutoxicatiou as cause of iritis,
319
Available accommodation, 146
Axenfeld, T., 243
Axial hyperopia, 147, 149
myopia, 155, 158
optic neuritis, 391, 397, 574
Axis of cylindrical lens, 168
BACTERIA, 67, 238, 242, 281
Bacteriologic examination, 67, 240,
242, 245, 252
Balance of muscles, 20, 24. 192
Ball, J. M., 585, 588, 591, 593
Ballooning of iris, 328
Band of light in pupil, 180
opacity of cornea, 302
Bandages, 528
Bane, W. C., 591
Base of prism, 106
Basedow's disease, 472, 534, 570
Benson, A. H., 593
Bibliography, 585-594
Bichlorid of mercury, 509
Biconcave lens, 114
Biconvex lens, 115
Bident, 425
Binasal hemianopsia, 37
Biniodid of mercury, 509
Binocular co-ordination, 198
diplopia, 46, 195. 197, 219, 220
fixation, 40
fusion. 195, 206
magnifier, 68
vision, 33, 157, 164, 191, 198, 213,
220
Bisnlphid of carbon, 400
Bitemporal hemianopsia, 37
Bjerrum's test of vision, 35
INDEX.
597
Black cataract, 412
Blackboard fields, 35
Blastomycosis, 448
.Bleeding, 323, 529
Bleuuorrhea, 243, 256
Blepharitis, 448
ciliaris, 449
marginal, 449, 575
Blepliarophimosis, 458
Blepharospasin, 56, 457
Blind spot, 33
Bliuduess, 32, 74, 218, 249, 340, 344,
442, 479, 498
Blood in anterior chamber. 408
Blood-vessels in vitreous, 430
Blue glass, 227
vision, 48
Blurring of sight, 147, 151
Boric acid, 510, 511, 514
Boroglycerid, 513
Bowman, Win., 434
Brachymetropia, 155
Brain abscess, 387, 567
disease, 389, 567
tumor, 387, 567
Brief recurring episcleritis, 243
Bright's disease, 367, 573
Brossage, 260
Brown, E. V. L.. 589
Bruise of eyeball, 481, 483
of lids, 479
Brims, H. D., 593
Buchanan, L., 592
Buchanan, M., 592
Bull, C. S., 589, 591, 592
Bull, G. J., 587
Buller, F., 590
Buller's shield, 249, 529
Bullous keratitis. 286
Bulson, A. E., Jr.. 591
Buphthalmos, 446
Burnett, S. M., 587, 589
Burning pain, 49, 239
Burns, 269.272. 311. 462
Byers, W. G. M., 590
CALHOUN, A. W., 590
Callan, P. A., 592
Calomel. 303, 520
Canal of Schlemm, 433. 443
Canalicnlns, disease of, 464, 540
Cant, W. E., 591
Canthoplasty, 261, 531
Canthotomy, 248, 261, 531
Capsule of lens, 77, 422, 553, 554
Capsulotomy, 423, 559
Carcinoma, 331, 353
Card records, 22
Caries, orbital, 470
spinal, 569
Carotid, rupture of, 473
Carpenter, G., 589
Carpenter, J. T., 588, 590
Caruncle, diseases of, 273
Case, history, 17
records, 20, 22, 28
Cassareep, 284
Cataphoria, 226
Cataract, 160, 407. 408, 553, 569
anterior polar, 281, 419
black, 412
capsular, 422
central, 421
choroidal, 412
complicated, 412, 555
congenital, 419
coraliform, 421
cortical, 412
diabetic, 414
diagnosis of, 413, 421, 423, 444
extraction, 417, 418, 553
fusiform, 421
glasses, 417
hard, 409
hypermature, 411
incipient, 411, 415
juvenile, 418
knives, 553
lamellar, 420
mature, 411, 413. 416
Morgagnian, 412
nuclear, 412, 418
operations, 553
partial, 419
perinuclear. 420
ripening operations, 416
secondary, 418, 422
senile, 409
soft, 418
swollen, 411
traumatic, 412, 482, 489, 496
treatment of, 415, 421, 423
vision after extraction of, 418
zonular, 420
Catarrh of conjunctiva, 237, 2.~3
255, 256, 575
Caterpillar hairs, 243. 493
Caustics, 272, 503, 506, 511
Cautery, 283, 547
Cavernous angioma, 460
sinus, thrombosis of, 469
Cavities adjoining orbit. 476, 583
598
IXDKX.
Cellulitis, orbital, 313. 578
Centers of vision, 32, '37, 4<>
Centrad, 111
Central cataract, 421
scotoma, 40, 397, 569. 574
Cerebral disease, 374. 389. 567
Ccrrbrospinal meningitis, 343, 579
Chalazion. 459, 537
Chancre, 268, 575
Chandler, H. B., 594
Charles, J. W., 587, 588
Chemosis, 65, 239, 244, 342
Chicken-pox. 579
Children, applications to, 507
Chlorid of mercury, 509
of zinc, 513, 514
Chloroform, 514
Chluroma, 476
Choked disk, 385
Cholera, 580
Cholesteriu crystals, 83, 408, 429
Chorea, 227, 570
Chorioretinitis, 369, 576
Choroid, 87, 99, 341, 567
Choroidal atrophy, 100, 101, 160,
174, 344, 347
cataract, 412
coloboma, 348
crescent, 86
detachment, 349
exudate, 101, 160, 174
hemorrhage, 349
inflammation. See Choroitlitis.
injuries, 483, 496
ossification, 349
pigment, 100
ring, 85, 100
rupture, 102, 484
sarcoma, 350
tuberculosis, 352, 575
vessels, 87
Choroiditis, anterior, 347
central, 346
diffuse, 347
disseminated, 346, 576
localized, 346
myopic, 160, 346
plastic, 344
purulent, 341, 579
senile, 347
Chronic conjunctivitis, 253
glaucoma, 435, 443
. opacities of cornea, 301
Cilia. 55, 529
Ciliary body, gumma of, 330
sarcoma of, 331
Ciliary body, wounds of, 488
muscle, 124, 129, 332
Cilioretinal vessels, N>
Circulation of blond in retina, 43
Circulatory disorders, 3H5. 374, 572
Claiborue, J. H., 592
Cleansing the eye, 246, 505, 507
Cleft lid, 448
Closure of punctutu, 463
Coats, G., 593
Coburn, F. B., 592
Cocain, 128, 322, 439, 515, 516, 51s,
519
Cold applications, 504
Colloid masses, 349, 393
Collyria, 504, 507, 511, 515
Coloboma of choroid, 348, 354
of iris. 374, 552
of lens, 425
of lid, 448
of optic nerve, 99, 397
Color fields, 47
of fundus, 87
of iris, 71
perception, 47
scotoma, 40, 397
tests, 40 .
vision, 47
Color-blindness, 48, 403
Coma, 568
Combined extraction, 417
Comitant squint, 200, 203, 214, 223,
225
Commotio retinae, 483
Complementary colors, 49
Complicated cataract, 412. 555
Complications of enncleation, 563
Compound astigmatism, 172. 173
Concave lens, 113, 114, 163. 167
mirror, 137
Concomitant squint, 200, 203, 214
223, 225
Concretions in conjunctiva, 271
Confusion colors, 49
Congenital amblyopia, 403
colobomas, 99, 348, 354, 425
color-blindness, 49,403
opacity of cornea, 296, 307, 576
squint. 198
, word-blindness. 406
Conical cornea, 187, 309, 547
Conjunctiva, 60, 237
foreign bodies in, 492
wounds of. 487
Conjunctival applications, 504, 506,
507, 509
INDEX.
599
Conjunctival catarrh. See Conjunc-
tivitis.
discharge, 66, 238, 243, 251, 254,
257
hemorrhage, 239
hyperemia, CO, 237, 577
operations, 537
swelling, 65, 239, 244, 251, 342
Conjunctivitis, catarrhal, 237, 253,
255, 261, 575, 577
contagious, 241, 243
croupous, 250
diagnosis of, CO, 65, 240, 242, 245,
251, 254, 259, 263, 320
diphtheritic, 250
diplobacillus, 242
exanthematous, 241
follicular, 256
granular, 256
lacrimal, 465
lymphatic, 261
membranous, 253
Parinaud's, 255
petrifying, 261
phlyctenular, 261, 575
prophylaxis of, 248
purulent, 243, 576
strumous, 261
treatment of, 240, 242, 243, 246,
252, 254, 256, 259, 263, 504,
509
vernal, 255
Connor, L., 588
Consensual reaction, 74
Contraction of pupil, 75, 316
of visual field, 41, 392, 397
Contusions, 479, 481, 483
Conus, 102, 161
Convergence, 57, 193, 205, 218, 226
Convergent squint. 208, 210, 222
Convex lens, 113, 115, 167
Convulsions, 568
Copper sulphate, 511
Coraliform cataract, 421
Corectopia, 353
Corelysis, 327, 552
Cornea, applications to, 504, 547
diseases of, 273
family degeneration of, 302
foreign bodies in, 493, 545
ring-abscess of, 274
temperature of. 275
transplantation of, 304
Corneal abrasions. 299
abscess, 278, 290, 291, 547
astigmatism, 172, 180
Corneal blood-vessels, 273, 288, 292,
294, 295
ectasia, 309
fistula, 447
gumma, 293
infiltration, 294
inflammation. See Keratitls.
macula, 301
nebula, 301
opacities, 70, 274, 277, 296, 300,
302, 502
operations, 545
phlyctenule, 288
pigment, 303
reflex, 70, 81, 83, 88
repair, 276
section, 284, 546, 553, 556
staphyloma, 305
surface, 17, 18
ulcer, 244, 276, 546, 578
wounds, 487
Correcting lenses, 146, 153, 163, 166,
170, 185, 221, 232, 348, 415,
417, 449
Corresponding points, 194
Corrosive sublimate, 509, 521
Cortical cataract, 412
Coryza, 581
Counting fingers, 29
Cover-test for squint, 199, 219, 227
Crater-like pupil, 328
Crede method, 249
Creeping ulcer, 278
Crossed blindness, 32
cylinder, 184
diplopia, 197, 209, 212
Croupous conjunctivitis, 66, 250
Crown glass, 111
Cryptoglioma, 381
Cryptophthalmos, 448
Crystalline lens, 77, 124
aberration of, 187
absorption of, 490
astigmatism of, 172
changes in, 124, 125, 408, 440
diseases of, 408
dislocation of, 424, 439, 443, 480,
482
injuries of, 480, 482. 489, 496
opacity of. See Catann-t.
removal of. 165, 417/553, 560
Culture-tests, 67
Culver, C. M., 586
Cupping of optic disk, 86, 97, 437
Curetting cornea, 283, 300, 546
Curvature hyperopia, 147, 149
600
INDEX.
Curvature myopia, 155, 158
Cutting lacrimal stricture, 542
Cyauid of mercury, 509
Cyclitis, 320, 324, 326, 334, 574, 576
Cyclophoria. See Rotary Deviation.
Cycloplegia, 127, 332, 481
Cycloplegics, 127, 222
Cylindrical lenses, 167, 183, 185
Cyst, coujuuctival, 271
of iris, 332
of lacrimal gland, 468
of lid, 460, 475
Cysticercus, 271, 380, 430, 460
Cystoid cicatrix, 447
Cystotome, 554
DACEYOADENITIS, 467
Dacryocystitis, 466
Dacryolith, 464 -
Dacryops, 468
Dalrymple's signs, 472
Darier, A., 593
Dark glasses, 348
room, 349, 501
Daturin, 127
Davidson, J. Mackenzie, 500
Davis, F. A., 586
Day-blindness, 359
De Beck, D., 591
Decentering of lenses, 232
Decussation at chiasm, 32
Degeneration, family, of cornea,
302
of iris. 329
Degree of prisms, 111
of squint. 192
Delirium, 568
Dendritic keratitis, 286
Dennett, W. S., Ill
Depth of anterior chamber, 407
Derby, H., 284
Dermatitis, 451
Dermoids, 266, 271, 311, 460, 474
Detachment of choroid, 349
of retina, 166, 352, 377, 573
of vitreous, 430
Developmental alexia, 406
Deviating eye, 192, 207, 214
Deviation by prisms, 111
of eye, 192, 207, 227
Diabetes, 315, 359, 368, 574
Diagnosis, 19
Diagrams, 21
Diathetic diseases, 574
Diet, 263, 297, 312
Dilatation of pupil, 75, 76, 440
Diminished tension of eyeball, 447
Dioniu, 520
Diopter, 117
Dioptric media, 105
system of numbering, 117
Dioptrics, 104
Diphtheria bacillus, 251, 252, 253,
281
Diphtheritic conjunctivitis, 66, 250,
578
paralysis, 212, 214, 333, 578
Diplobacillus, 242, 281
Diplococcus, 238, 256
Diplopia, 46, 194, 195, 197, 202, 206,
207, 214, 219, 404, 424
Direct massage of lens, 416
method, 131
Discission for cataract, 558
Discoloration of conjunctiva, 273
Disk. See Optic Disk.
Disks, gelatin, 507, 508
Dislocation of eyeball, 480
of lacrimal gland, 468
of lens, 424, 439, 445, 480, 482
Dispersion of light, 110
Displacement, lateral, of tendon in-
sertion, 223, 545
of punctum, 464
Distention of eyeball, 161, 432, 446
Distichiasis, 454, 529, 530
Distortion of images, 45
Divergent rays, 104
squint, 157, 209, 212, 221
Division of tarsal ligament, 533
of upper lid, 248, 533
Dodge, R., 587
Donders, F. C., 586
Donovan, J. A., 592, 593
Double concave lens, 115
convex lens, 114
images, 208
prism, 229
vision. See Diplopia.
Douche, 505
Doyne, E. W., 588
Dragged disk, 162
Dressings, 527
Drug eruptions, 451
Drusen, 349, 393
Duane, A., 585, 587, 588
Dubnisin, 127, 517,518
Dusting powders, 511
Dyslexia, 571
ECCHYMOSIS, conjunctiva!, 270, 498
of lids, 479, 498
INDEX.
601
Ectopia lentis, 424
Ectropion, 456, 534
organic, 456
paralytic, 456, 534
uvese, 331, 353
Eczema, 261, 451
Edema of conjunctiva, 270
of lids, 64, 459, 579
of retina, 362, 573
Edge of prism, 110
Edsall, D. L., 590
Edson, C. E., 585
Educative treatment of squint, 223
Electricity, 213, 304
Electric-light retinitis, 371
Electrolysis, 267, 530, 537
Electro-magnet, 498
Elevator, lid, 526
Ellett, E. C., 594
Embolism of retinal artery, 570, 574
Emmetropia, 123, 139
Emphysema, 64, 270, 459, 479
Encauthus, 273
Encephalocele, 475
Enophthalmos, 471, 480
Entoptic method, 42, 44
Entropion, organic, 455, 530
spasmodic, 455, 530
Enucleation of the eye, 338, 341,
343, 561
Epicanthus, 458
Epidermoid pearl of iris, 332
Epilation-forceps, 530
Epilepsy, 227, 569
Epiphora, 462, 569
Episcleritis, 243, 311
Epitarsus, 448
Epithelial grafting, 534, 538
Epithelioma, 271, 461
Equivalent lenses, 116
Erect image, 131, 138
Errors of refraction, 124, 144
Erysipelas, 343, 441, 452, 580
Erythema, 451
Erythropsia, 48
Eserin, 129, 442, 519
Esophoria, 226
Ether, 514
Ethmoidal disease, 389, 478
Ethylate of sodium, 460
Eucain, 515
Euphthalmin, 129, 516
Eve, 383
Eversion of lids, 57
Evisceration of the globe, 338, 341,
564
Examination, bacteriologic, 67
entoptic, 42, 44
microscopic, 67
of case, 17
of conjunctiva, 60
of eye, 18, 568
of lids, 55
ophthalmoscopic, 18, 80, 84, 131,
142, 176, 496
Exanthematous conjunctivitis, 241
eruptions, 451
Excision of anterior staphylonia,
308, 548
of cervical sympathetic, 441
of chalazion, 460, 537
of pterygium, 266, 537
of roots of lashes, 531
Exciting eye, 334
Exclusion of light, 501
of pupil, 327
Exercises, gymnastic, 213, 223, 233
Exophoria, 226
Exophthalmic goiter, 472, 534, 570
Exophthalmos, 65, 469, 471, 472,
480
Exostosis, 476
Expression for trachoma, 259, 539
Extended tenotomy, 544
External rectus, 208, 210
Extirpation of lacrimal sac, 460,
542
Extract of suprarenal body, 520,
529
Extraction of cataract, 417, 553, 557
of foreign body, 493, 495. 498,
545, 560
Eyeball, dislocation of, 480
operations on, 560
prominence of, 55
rupture of, 480
Eyebrows, 454
Eye-douche, 505
Eye-glasses, 189
Eye-ground, 84
Eyelashes, 55
Eye-shade, 528
Eye-strain, 17, 145, 150, 157, 160,
174, 227, 253, 314, 324, 388,
440, 449, 569, 570, 572
Eye-symptoms of general diseases,
566
FACIAL paralysis, 457
Facultative hyperopia, 149
Failure of accommodation, 147, 151
False image, 197, 207
602
INDEX.
False scotoma, 39
Family degeneration of cornea, 302
history, 18
Far-point, 148
Far-sight, 147
Fatty degeneration in retina, 91,
359
Fibroma, 271, 460, 476
Fibrosarcoina, 476
Field of vision, 23, 33, 47, 373, 377,
391, 437, 443, 498, 567, 569, 571
for colors, 47, 392, 397
Filamentous keratitis, 287
Filaria, 271,430
Filix mas amblyopia, 402
Finger-tests, 29, 36
Fisher, J. H., 591
Fissures of lids, 263, 264, 289, 451
Fistula, lacrinial, 467
of lid, 468
Five-minute angle, 27
Fixation for operation, 526
point, 192
Fixing eye, 192, 207
Flame-shaped hemorrhages, 91, 360
Flashes of light, 45, 345
Flint glass, HI
Fluid vitreous, 428
Fluorescin, 494, 520
Focal distance* 116
illumination, 68
lines and interval, 170, 173
Focus, 113
Focussed light, 104
Fogging, 121
Follicular conjunctivitis, 256
Fomentations, 503
Forceps, 526. 527, 529. 530. 550
Foreign body, 51. 265, 271
in anterior chamber, 495
in choroid, 496
in conjunctiva, 492
in cornea, 493, 545
in iris, 495
in lens. 496
in lids and orbit, 492
in retina, 496
in sclera, 495
in vitreous, 496. 560
sensation of a, 53, 239
Formaldehyd, 508
Fovea, 89
Fracture involving orbit, 479
Friedenwald, H., 589
Frontal sinus. 477
Frost,, W. A., 585
Fuchs, E., 585, 588
Full correction, 153
Fundus, influence of light on color
of, 143
reflex, 81, 84
Fusiform cataract, 421
Fusion binocular, 224
training in squint, 221
tubes, 220
GALVANISM, 466
Galvano-cautery, 283, 547
Gamble, W. E., 589, 590
Gangrene of lids, 453
Gelatin disks, 507, 518
General anesthesia, 514
diseases, 19, 157, 566
rest, 501
Gibbons, E. E., 585
Giflbrd, H., 243, 588, 589
Glasses, changes with age, 190
smoked, 501
Glaucoma, 407, 418, 434, 569, 574, 576
absolute, 436
acute, 435
chronic, 435, 443
cup, 98, 437, 443
diagnosis of, 440, 444
fulminant, 436
hemorrhagic, 444
incipient, 435
inflammatory, 435
iridectomy, 441, 551
malignant, 443
post-iritic, 445
primary, 435, 443
secondary, 444
simple. 443
treatment of, 441, 444, 502, 5E1
with exacerbations, 435
Glioma or gliosarcoma of retina,
352, 380, 445
Glycerol of tannin, 512
Goiter, exophthalmic, 534, 570
Golovine, 478
Gonococcus, 243, 245
Gonorrheal conjunctivitis. 243. 245.
282, 576
iritis, 319, 576
Gould, Geo. M., 587
Gout. 312, 368, 440, 574
Gowers, W. E., 32
Gradle, H., 593
Graduation of trial frames, 168
Graefe's knife, 553
sign, 472
INDEX.
603
Graefe's test, 229
Grafts, epithelial, 535, 538
(Irani method, 67
Grandclement, 356
Granular conjunctivitis, 256
Granulated lids, 244, 254, 256
Grattage, 260
Graves's disease, 472, 570
Green, John, 586
Grippe, 578
Grossmann, K., 587, 593
Ground glass, 214
Growth .of lens, 440
Gruening, E., 593
Guuima of cornea, 293
of iris and ciliary body, 330
Gunn, Marcus, 589
Gygax, 593
Gymnastic exercises, 213, 223
HAAB, A., 592
Haab, O., 586, 593
Haab's magnet, 561
Hale, A. B., 587
Hallucinations, 583
Halo atrophy, 438
symptom, 435
Hanke, V., 593
Hansell, H. F.. 589, 590, 592
Hard cataract, 409
Harlan, G. C., 588,591
Harlan's test, 404
Barman, N. B., 587
Harris, W., 590
Hartridge, G., 586
Hay, P. J., 586
Haziness of retina. 90
Headache, 52, 53, 151, 160, 174, 205,
227, 567
Heart disease, 572
Heat. 248, 502, 507
Homianopsia, 34. 36, 42, 74, 403
Hemichromatopsia, 38, 48
Hcmioriia and hemianopia. See
.Hemianopsia.
Hemorrhage, choroidal, 349
conjunctival. 239
following cataract extraction,
556
in anterior chamber, 408
into vitreous. 429, 482, 497
retinal. 90, 360
Hemostatics, 503, 520, 529. 556
Hereditary optic atrophy, 393
syphilis, 295, 576
Herpes of cornea, 286, 287, 292
Herpes of lids, 451
zoster, 452
Heterocliroiuia, 353
Heterophoria, 204, 225, 226, 231
Hinshelwood, J., 590
Hippus, 73, 332
Hirschberg, J., 592
Hirschberg's magnet, 560
History of case, 17, 18
Holden, W. A., 281
Hole in macula, 374
Holmgren test, 49
Holocain, 284, 515
Homatropin, 127, 128, 516, 517, 519
Homonymous diplopia, 197, 208, 209,
210
hemianopsia, 36
Hordeolum, 450
Horn-like growths, 453
Horopeter, 194
Hot applications, 502, 503, 529
Hotz, F. C., 175, 176, 594
Howe, Lucien, 587
Hubbell, A. A., 592
Hulen, V. H., 592
Hutchinson, Jonathan, 292, 295
Hutch in son's teeth, 295
Hyaline bodies, 349, 393
Hyalitis, 429
Hyaloid artery, 431
Hydatids, 430
Hydraulic curetting, 283
Hydrogen dioxid, 508, 529
Hydrophthalmos, 446
Hyoscyamin, 127, 517, 518
Hyperemia of conjunctiva, 60, 237,
261
of glaucoma, 63
of iris, 71, 315
of optic disk, 93, 383
of retina, 92, 358
of sclera, 63
pericorneal, 61, 315, 324
Hyperesthesia of the retina, 358
Hypermature cataract, 411
Hypermetropia, 147
Hyperopia, 123, 131, 139, 147, 221
absolute, 149
axial, 147
facultative, 149
latent, 149
manifest, 149
of curvature, 147
total, 149
Hyperopic astigmatism, 173
Hyperostosis, 476
604
INDEX.
Hyperphoria, 226
Hypertrophy of conjunctiva, 244,
245
of lids, 475
of ocular muscles, 236
Hypheruia, 408
Hypopyon, 290, 407
Hysterical amblyopia, 403, 571
squint, 234, 572
ILLUMINATION, focal, 68, 525
of tests, 29
Images, true and fals?, 196, 207
Impairment of vision, 25, 30, 41,
147, 151, 158, 173, 318, 358,
391, 409, 436
Implantation of artificial vitreous,
565
Inch system of numbering lenses,
116
Incipient cataract, 411
glaucoma, 435
Incision, iutermarginal, 530
of chalazion, 537
of cornea, 284, 344. 546, 553
Inconstant impairment of vision, 41
Index of refraction, 104, 1 10
Indirect massage of lens, 416
method, 131, 142
Inequality of pupils, 75
Infantile cerebral degeneration, 374
Infectious diseases, 575, 577
Inferior oblique, 209, 211
rectus, 209, 211
Infiltration anesthesia, 515
lymphoid, of lids, 64
Influenza, 578
bacillus conjunctivitis, 241
Ingrowing lashes, 455
Inherited syphilis, 295, 576
Injections, subconjunctival, 507
Injuries of choroid, 483, 496
of ciliary body, 481
of conjunctiva, 487, 492
of cornea, 487, 493
of eyeball, 480
of iris, 481, 488, 495
of lens, 480, 482, 489
of lids, 479, 492
of orbit, 479, 492
of retina, 583, 496
of vitreous, 491, 496
Innenpol magnet, 561
Inoculation for pannus, 300
Insanity, 571
Inspection of the eye, 17, 71
Instillations, 504, 515, 520
Instruments, 524, 526
Insufficiencies, muscular, 203, 225,
231
Intention nystagmus, 234
Intermarginal incision, 530
Internal rectus, 209, 211
Interstitial nephritis, iritis in, 319
Intoxication, mydriatic. 128
Intracrauial disease, 567
Intra-ocular currents, 432, 439
tension, 432, 434
tumors, 350, 352, 380, 445
Inverted image, 131, 135, 138, 142
lodid of potassium, 303, 521
lodin, 513
lodoform, 511, 513
amblyopia, 400
Iridectomy, 304, 307, 327, 339, 421,
549, 557
for glaucoma, 441, 442, 447, 551
optical, 304, 307, 339, 421, 551
preliminary, 416, 549
with cataract extraction, 417, 557
Iridencleisis, 553
Irideremia, 354
Iridochoroiditis, 341
Iridocyclitis, 324, 334, 447
Iridocystectorny, 552
Iridodesis, 553
Iridodialysis, 481
Iridodonesis, 332, 423
Iridoplegia, 332, 481
Iridotomy, 552
Iris, 17, 71, 313
bomhe, 328
cyst, 332
diseases of, 313
foreign body in, 495
gumma of, 320
injuries of, 481, 488
prolapse of, 284, 480, 488, 556
sarcoma of, 331
trembling of, 332, 423
tuberculosis of, 330
tumors of, 331
Iritis, 313, 314, 441
diabetic, 319
diagnosis of, 61, 71, 320, 325, 337,
440, 441
fibriaons, 318
gonorrheal. 319, 321
gouty, 319, 321
insidious, 318
malarial, 321
parenohymatous, 318
IXDEX.
605
Iritis, plastic, 318
purulent, 318
quiet, 318
rheumatic, 314, 319, 321
sequels of, 326
serous, 319, 324
spongy, 318
syphilitic, 314, 319, 321
traumatic, 320, 489
treatment of, 321, 326, 552
Irregular astigmatism, I(i7, 1ST, 410
Irrigators, 247
Irritants, 237, 303. 511
Irritation, sympathetic, 334, 337,
340
Ischemia of the retiiia, 359
Itching, 52, 239
Ivory exostosis, 476
JACKSON, E., 585, 586, 587, 590, 591,
592, 594
Jacob's ulcer, 461
Jamaica ginger amblyopia, 402
Javal, E., 585
Javal and Schiotz ophthalmometer,
178
Jennings, J. E., 586
Jequirity, 300, 513
Johnson, W. B., 446
Jonnesco, T. 441
KKRATECTASIA, 309
Keratectomy, 548
Keratitis, 187
bullous, 286
diagnosis of, 277, 281, 286, 294,
299, 320, 440
diffuse, 292
fascicular, 288
filamentous, 287
interstitial, 292
lymphatic, 288
marginal, 294
neuropathic. 287
oyster-shuckers', 494
parenchymatous, 292
phlyctenular, 288
punctate, 297, 318, 324
sclerosing, 294, 312
scrofulous, 288, 292, 294
striate, 297
superficial vascular, 292, 298
trachomatous, 298
traumatic, 494
treatment of, 277, 282, 286, 288,
291, 296, 299
Keratitis, ulcerous, 276, 286, 320
vascular, 288
Keratocouus, 309
Keratoglobus, 310, 407
Keratomalacia, 287
Kidney disease, 572
Kipp, C. J., 588, 590, 593
Klebs-Loffler bacillus, 251, 252, 253,
281
Knapp, A., 592
Knapp, H., 249, 260
Kuapp's roller-operation, 260, 539
Kroulein's operation, 566
Kyauopsia, 48
LACKIMAL abscess, 467
conjunctivitis, 253, 465, 523
disease, 18, 462, 523
fistula, 467
gland, diseases of, 467
obstruction, 465, 466, 523, 540,
542
regurgitation, 253, 281, 465, 523
tumor, 465
Lacrimation, 341, 463, 464, 465, 523
Lactation, 581
Lagophthalmos, 456
Lamina cribrosa, 86, 91
Landolt, E., 593
Lanolin, 513
Lapis divinus, 512
Lashes, 56, 261, 454, 529
Latent hyperopia, 149
squint, 204, 225
Lateral displacement, 223, 545
nystagmus, 235
Law of sines, 108
Lawson, A., 588
Lead capacity of cornea, 302
Lead-poisoning, 366, 389
Leeches, 529
Length of visual axis, 134
Lens. See Crystalline Lens.
Lenses, 112, 164, 167
before eye. 143
oblique, effects of, 189
periscopic, 190
Lens-series, 79. 118
Lenticonus, 426
Leprosy, 451, 577
Leptothrix, 464
Letter-blindness, 571
Leucoma, 70, 301, 405
Leukemia, 363, 572
Lid-elevator. 526
Lid-margins, 56, 60, 449
606
INDEX.
Lids, 56, 64, 448
adhesions of, 66
anomalies of, 448
bruise of, 479
colobonia of, 448
diseases of, 448
foreign body in, 492
operations on, 529
Liebreieh bandage, 528
Light difference, 30
in pupil, 14U
influence of, on color of fundus,
143
minimum, 30
perception, 30, 140
projection, 29, 409, 414
reactions to, 73
refraction of, 104
sense, 30
streak on retinal vdfcsels, 86, 359
waves, 104
Lime-burns, 272
Linear extraction, 557
Lines in astigmatism, 171
Lipoma, 271. 460
Lippitudo, 449
Local anesthesia, 514
Locomotor ataxia, 568
Loring, E. G., 585
Loupe, corneal, 68
Lupus, 268, 461
Luxation of eyeball, 480
of lens, 424, .439, 445, 480, 482
Lymphatic glands, enlarged, 255,
453
Lymphoid infiltration of lids, 64
Lymphoma, or lymphoid tumor,
466, 476
MACULA, hole in, 374
lutea, 43, 88, 101
of cornea, 70, 301
Macular reflex, 89
region, anomalies of. 382
Maddox, E. E., 587
Maddox rod, 228
Magnet-extraction, 498, 560
Magnifiers, 68
Malaria, 577
Malarial ulcer, 286
Malignant glaucoma, 443
myopia, 158
Manifest hyperopia, 149
Marginal keratitis, 294
Marple, W. B., 588, 589, 590, 591
Marshall, C. D., 589
Ma.sk to protect eye, 528
Massage, 312, 442, 501
of crystalline lens, 416
Mature cataract, 411
Maxillary antrurn, 477
Mayou, M. S., 586
McKeyuolds, J. O., 538, 591
Measles, 241, 577
Measurement of refraction, 131. 133,
134
of squint, 201, 229
Mechanical injuries, 479
Medicated gelatin disks, 507, 518
Medullated nerve-fibers, 91, 381
Meibomian glands, 271
Melanomata, 331
Meningitis, 343, 381, 567, 579
Meningocele, 475
Meniscus lenses, 115
Menstruation, 581
Mental confusion, 227
Mercurial preparations, 303, 509,
513, 520
Meridians of astigmatism, 169
Metamorphopsia, 358, 377
Metastasis, 342, 352, 362
Meter-angle, 193
Methyl alcohol, 400
violet, 510
Metric numbers of lenses, 117
Microphthalmos, 475
Microscopic examinations, 67, 242,
243, 245
Migraine, 45, 570
Migratory ophthalmia, 334
Miles, H. S., 594
Milium, 453
Mind-blindness, 571
Miners' nystagmus, 234
Mirror, ophthalmoscopic, 130
skiascopic, 136, 137
Misplaced lashes, 455, 529
puncta, 464
Mitigated silver nitrate, 512
Mixed astigmatism, 173
Molluscum, contagious, 452
Monocular blindness, 32
diplopia, 46, 424
neuritis, 389
polyopia. 410
squint, 217
tests, 32, 46
Monoscope, 221
Morax. V.. 243, 273
Morgagnian cataract, 412
Motais' operation, 536
INDEX.
607
Mounting glasses, 189
Movement, disorders of, 17, 191,
205, 332
Movements of eyeball, 57, 159, 191,
200
of lids, 56
Moving objects, 29, 410
Mucous grafts, 538
Mules' operation, 565
Multiple images, 46, 219, 410, 424
neuritis, 391, 569
Mumps, 467, 579
Muscse volitantes, 42, 160, 428
Muscles, ocular, 17, 191
diseases of, 236
hypertrophy of, 236
operations on, 543
pseudohypertrophy of, 236
rheumatism of, 236
Muscle-stretching, 213
Muscular balance, 20, 24
imbalance, 225
insufficiencies, 225, 568
Myasthenia "gravis, 571
Mycotic ulcer of cornea, 286
Mydriasis, 76, 127, 332,440
Mydriatics, 80, 127, 321, 439, 516
attack, 322
Myelitis, 569
Myopia, 65, 123, 133, 134, 155, 345,
378, 407, 560
axial, 155
following iritis, 326
malignant, 158, 446
of curvature, 155
preceding cataract, 410
progressive, 158
temporary, 158
Myopic astigmatism, 173
crescent, 100, 101, 161, 345
Myosis, 76, 129, 316, 332
Myositis, 236
Myotics, 129. 442, 519
NARROWING of visual field, 41. 48
Nasal disease, 263, 465, 582
duct, 465, 523, 540
hemianopsia, 37
Nausea, 206, 568
Near-point, 126, 145, 154
of convergence, 193, 201, 226
Near-sight, 155, 162, 410
Nebula, 70, 301
Necrosis, orbital, 470
Negative aberration, 186
scotoma, 39
Neonatorum, ophthalmia, 243. 249
Nephritis, interstitial, iritis in, 319
Nerve-head, 85, 94, 391
Nervous disease, 567
Nettleship, E., 586, 588, 589, 590,
591
Neuralgia, 52, 440
Neurasthenia, 571
Neuritis, 385, 569
Neuroma of lids, 460
Neuropathic or ueuroparalytic
keratitis, 287, 292
Neuroretinitis, 384
Nevus, 460
Night-blindness, 358, 369, 373
Nipping of the lids, 159
Nitrate of silver, 509, 512
Nitrobenzol amblyopia, 400
Nodding spasm, 235
Normal irregular astigmatism, 188
Nuclear cataract. 412
palsies, 214
Numbering of lenses, 116, 118
of prisms, 111
Nystagmus, 192, 234
OATMAN, E. L., 588, 589
Object lens, 142
Objective tests for malingering, 405
Oblique illumination, 68
lenses, effects of, 189
Obliquely placed lenses, 164
Obstruction, lacrimal, 465
of canal iculus, 464
of nasal duct, 465
of retinal vessels, 374
Occlusion of pupil. 327. 439
Occupation of patient, 21
Ocular movements, 191, 192
muscles, diseases of, 236
hypertrophy of, 236
pseudohypertrophy of, 236
rheumatism of, .236
palsies, 205
Oculo motor paralysis, 65, 205, 214,
218
Ohlemann, F. W. M., 593
Ointments, 513
Oliver, C. A., 589, 593
Onyx, 290
Opacity of cornea, 70, 81, 274, 277,
300, 502
of crystalline lens, 82
of optic nerve-head, 94
of vitreous, 82, 83, 335, 370
Opaque nerve-fibers, 91, 381
608
INDEX.
Operations for cataract, 419, 421,
423, 553
for pterygium, 266, 537
for ripening cataract, 416
for squint, 214, 222, 225, 233, 470
543
for syuiblepharon. 270, 538
on conjunctiva, 537
oil cornea, 545
on crystalline lens, 553
on eyeball, 560
on iris, 549
on lacrimal passages, 540
on lids, 529
on muscles, 470, 543
on sclera, 549
ophthalmic, 523, 525
plastic, 535
Ophthalmia, 237, 250
Egyptian, 256
gonorrheal, 243, 245, 249, 282
neonatorum, 243, 245, 249
nodosa, 243, 320
phlyctenular, 261
purulent, 243
strumous, 261
sympathetic, 333, 488
Ophthalmic migraine, 45
Ophthalmomalacia, 447
Ophthalmometer, 172, 178
Ophthalmoplegia externa, 76, 205
in tern a, 76, 332
Ophthalmoscope, 78, 130, 152, 176
Ophthalmoscopic examination, 18,
78, 80, 84, 131, 143, 176, 497
special methods, 143
Optic atrophy, 98, 391, 398, 567
choroiditic, 393
consecutive, 393
gray, 394, 568 . ,
hereditary, 393
neuritic, 393
postpapillitic, 393
primary, 393
retinitic, 393
secondary, 393
simple, 394
white, 394
chiasm. 32
disk, 84, 93, 383, 443
foramen, fracture of, 479
nerve, 84, 99, 383, 397
atrophy. See Optic atrophy.
head, 384, 397
neuritis, 385, 391, 567
papilla, 383
Optical center of lens, 114, 232
iridectomy, 421, 551
Orbit, disease of, 468
foreign body in, 492
Orbital abscess, 470
cellulitis, 343, 468, 470
cysts, 474
fractures, 479
optic neuritis, 391
periostitis, 470
tumors, 475
wall, osteoplastic resection of, 566
Organic compounds of silver, 510
Orthophoria, 226
Orthoptic exercises, 223
Oscillation of eyeball, 57, 192, 234
Osier, Win., 592
Ossification of choroid. 349
Osteoma, 271, 476
Osteoplastic resection of orbital
wall, 566
Overcoming prisms, 192
PAIN, 51, 54, 238, 287, 315, 323, 437
Pallor of optic disk, 96
Panas, P., 536
operation of, 536
Pannus, 298, 502
Panophthalmitis, 341, 469
Papilla, optic, 383
Papillae, enlarged, 244, 253, 258
Papillary granulations, 244, 245
Papillitis, 385
Papilloma, 271
Papillomacular bundle, 391, 397
Papilloretinitis, 384
Paracentesis of cornea, 284, 546
Paraffin, sphere of, 565
Parallel lines, 183
rays, 104
Paralysis, diphtheritic, 333
of accommodation, 214, 332, 481
of iris, 76, 127, 332, 481
of ocular muscles, 200, 203, 204,
214, 479
of orbicularis, 456
Paralytic squint, 200, 203, 204, 214,
*479
Parasites in vitreous, 430
Paresis of ocular muscles. 226, 568
Parinaud's conjunctivitis, 255
Parsons, ,T. H.,'585, 590, 593
Partial correction, 154
tenotomy, ."1 1
Pathology of sympathetic inflam-
mation, 335
INDEX.
609
Pediculosis, 454
Pemphigus of conjunctiva, 267
Perception of light, 30
Perforating corneal ulcer, 245, 279
Pericorneal redness, 61, 315, 494
Perimeter, 34, 35, 201
Period of adaptation of glasses, 190
Periostitis, orbital, 470
Periscopic lens, 115, 185, 190
Peritomy, 300, 539
Permanganate of potassium, 510
Pernicious anemia, 363, 572
Peroxid of hydrogen, 508, 529
Persistent hyaloid artery, 430
pupillary membrane, 353
Pertussis, 579
Petrifying conjunctivitis, 261
Phillips, E. J., 587
Phlegmon of orbit, 468
Phlyctenular conjunctivitis, 261
hyperemia, 61, 262
Phlyctenule, 262, 288
Photometer, 30
Photophobia, 17, 276, 277, 288, 341
Phthiriasis ciliorum, 454
Phthisis bulbi, 350
Physiological cup, 86, 97
Physostigmin, 129, 442, 519
Pigment in conjunctiva, 273
in cornea, 303
Pigmentary degeneration, 372
Pigmentation of fundus, 87, 99, 316,
326, 328
of retina, 99, 361
Pilocarpin, 129, 442, 519, 522
Pince-nez, 189
Pinguecula, 266, 267
Pin-hole disk, 31
Pipette, 247
Placido's disk, 71
Plane mirror, 136
Plano-concave lens, 115
Plano-convex lens, 114
Plastic choroiditis, 344
conjunctivitis, 250
iritis, 318
operations, 535
Pneumococcus, 238, 242, 281
Point of light, 45, 174
of reversal, 135, 138, 181
Poison ivy, and oak, 451
Poisons, 397, 583
Pollock, W. B. J., 587
Polycoria, 353
Polyopia, 410. See also Diplopia.
Polypi, nasal, 582
39
Pooley, T. R., 591
Posey, W. C., 585, 590, 592, 598
Position for operating, 524
Positive aberration, 186
scotoma, 39, 345
Posterior sclerosis, 393, 568
staphyloma, 162, 313
symblepharon, 270
synechia, 71, 76, 293, 316, 326,
328
Potassium iodid, 303, 521
permanganate, 508
Poultices, 503
Powder grains, 492, 494. 547
Powders, 511
Pregnancy, 366, 581
Preliminary iridectomy, 549
Preparation of instruments, 524
of patient, 523
of surgeon, 524
Presbyopia, 144, 154, 164
Pressure-bandage, 528, 529
on the eye, 32
within eyeball, 432
Prince, A. E., 259
Principal focus, 116
meridians, 169
Prism convergence, 193
diopter, 111
divergence, 193
Prismatic colors, 110
Prisms, numbering of, 110, 111
• refraction by, 109, 111
uses of, 192, 203, 205, 213, 220,
224, 229, 232, 404
Probing lacrimal passages, 466, 541
Progressive myopia, 158, 166
Projection, 194, 197
light, 29
Prolapse of iris, 284, 480, 488, 556
of lens, 480
of vitreous, 499, 556
Prominence of eyeball, 55
Prophylaxis of purulent conjunc-
tivitis, 248
of sympathetic inflammation, 337
Proptosis. See Exophthalmoa.
Protargol, 247, 510
Protectors, 528
Pseudo-accommodation, 125
Pseudo-glioma, 343, 381, 429
Pseudo-hypertrophy of ocular
muscles, 236
Pterygium, 265, 537
Ptosis, 56, 457, 536
congenital, 458
610
INDEX.
Ptosis, operations, 536
paralytic, 457
Puerperal fever, 580
Pulsating exophthalmos, 472
Pulsation of retinal vessels, 86, 437
Punctate keratitis, 297, 318, 324
Punctual, diseases of, 463
proximum, 126, 145
remotum, 148
Pupil, 17, 71, 72, 77, 127, 130
Argyll-Robertson, 74
distortion of, 317, 324, 327, 353
in cataract, 409, 415
reflex from, 81, 140, 187
Wernicke, 38, 75
Pupillary reactions, 72
Pupillometer, 72
Purkinje, figures of, 43
Purpura, 575
Purulent cpnjunctival discharge, 66
conjunctivitis, 243, 469
Pusey, B., 589
Pus-organisms, 281
Pyemia, 342, 363, 580
Pyle, W. L., 589
Pyoktanin, 510
QUADRANT defect, 38
Quantitative perception of light,
29, 414
Quinin amblyopia, 401
RABBIT'S eye as support for arti-
ficial eye, 565
Race, 257, 374, 438
Radiating lines, 175
Radiographs, 492
Randall, B. A., 586
Randolph, R. L., 591
Ray, J. M., 592
Rays of light, 104
Reactions of iris and pupil, 17, 72
Reading bar, 223
Real focus, 114
movement, 137
Records of cases, 20
of vision, 28
of visual field, 36
Recovery after deviation, 227
Recurrent oculomotor paralysis,
205, 215
Red vision, 48
Redness of conjunctiva, 60
of optic disk, 93
Reduced eye, 122
ocular tension, 447
Reflex epiphora, 463
from cornea, 70, 81, 83
from lens, 77
fundus, 81, 89
Refracting angle, 110, 111
power of lens, 116 .
of prisms, 110
Refraction by glass, 106
by cylindrical lenses, 167
by prisms, 110
by spherical lenses, 113
measurement of, 131, 134, 152, 162,
174
of light, 103, 104, 167
of eye, 123
Refractive index, 105
Regular astigmatism, 167, 169
Regurgitation, lacrimal, 253, 281,
523
Reid's ophthalmometer, 179
Reik, H. O., 594
Relapsing fever, 580
Relative divergence, 218
hemianopsia, 38
scotoma, 39
Remedies and their application, 500
Removal of clear lens for myopia,
165, 560
Renal disease, 365, 573
Resection, osteoplastic, of orbital
wall, 566
Rest of the eyes, 500, 501
Retained nerve-sheath. See Opaque
nerve-fibers.
Retina, 87, 90, 92, 357, 567
glioma of, 380
injuries of, 483, 496
Retinal anemia, 359
anomalies, 381
apoplexy, 364
atrophy, 361
degeneration, 361, 372
detachment, 166, 377, 573
embolism, 365, 374
hemorrhage, 90, 360, 573
hyperemia, 92, 358
hyperesthesia, 358
images, 123, 165. 175, 191
inflammation, 362
ischemia* 359
macular atrophy, 374
opacity, 360, 483
pigment, 99
pigment-changes, 361, 372
reflexes, 89, 162
thrombosis. 365, 376
INDEX.
611
Retinal vessels, 43, 86, 92, 359,
393
Retinitis, 348, 362
albumiuuric, 365, 573
circinate, 371
diabetic, 368, 574
diagnosis of, 362, 364, 366, 370,
373
embolic, 362
from excessive light, 371
gouty, 368
hemorrhagic, 364
leukemic, 363
malarial, 364
metastatic, 362
pigmentosa, 372
proliferans, 371, 427
punctate, 370
purulent, 362
septic, 363
serous or simple, 362
striate, 370
syphilitic, 369
treatment of, 362, 364, 365, 367,
370, 373
Eetinoscopy, 135
Retraction of lids, 56, 472, 525
Retrobulbar optic neuritis, 379, 391
Retrotarsal fold, 59
Reversal, point of, 135, 138, 181
Rhagades, 263, 264 289, 451
Rheumatism, 212, 214, 311, 314, 440,
574
of ocular muscles, 236
Rhinitis, 582
Rhus poisoning, 451
Riders, 421
Ring dressing, 528
scotoma, 41
ulcer, 278
Ring-abscess of cornea, 274
Rings around the light, 46
Ripening operations, 416
Risley, S. D., 593
Robertson, Argyll, 534
Rodent ulcer, 461
Rogers. F. C., 591, 594
Roller-forceps operation, 260, 539
Rontgen rays, 492, 496, 498, 500
Rosy zone, 62, 277, 292, 315, 324, 436
Rotary deviation, 230
nystagmus, 234
variable prism, 231
Rule, astigmatism with or against,
169
Rupture of choroid, 102, 483
Rupture of eyeball, 480
of iris, 481
SAEMISCH incision, 284, 546
Salicylic acid amblyopia, 402
Salt solution, 510
Santonin, 583
Sarcoma of choroid, 350, 444
of conjunctiva, 271
of lids, 461
or orbit, 475
Savage, G. C., 587
Scalping lid, 531
Scarlet fever, 241, 365, 578
Scars, 17, 485, 486
Schiotz and Javal's ophthalmom-
eter, 178
Schleich's local anesthesia, 515
Schlemm, canal of, 433, 443
Schneideman, T. B., 589, 591
Schweigger, C., 236, 431
Schweinitz, Geo. E. de, 585, 586, 588,
589, 590, 591, 592, 593
Schwenk, P. N. K., 591
Sclera, diseases of, 311
thinning of, 157
wounds of, 488, 495
Scleral, crescent, 86
hyperemia, 62
ring, 86
staphyloma, 33, 157
Scleritis, 311
Sclerosing keratitis, 294, 312
Sclerosis, spinal, 393, 568
Sclerotomy, 441, 447, 549
Scoop-extraction, 425, 557
Scopolamin, 127, 517, 518
Scotoma, 39, 345, 397, 403
central, 40, 397, 569, 574
color, 40, 397
negative, 39
positive, 39, 345
ring, 41
temporary, 42, 570
Scurvy, 575
Second sight, 410
Secondary cataract, 422
contraction, 206
deviation, 206
Sector-like defect of field, 38, 397
Senile cataract, 409
Sensations, visual, 44
Sense, light, 30
Septicemia, 342, 363, 580
Sequels of iritis and cyclitis, 326
Serpent ulcer, 278, 279, 281
612
INDEX.
Sexual disorders, 581
Shadow-test, 135
Shingles, 452
Shoemaker, W. T., 592
Short sight, 155
Shotted-silk retina, 89
Shrinking of conjunctiva, 260, 261,
268
of eyeball, 350
of nerve-head, 391, 393
Shumway, E. A., 588, 590
Sight. See Vision.
Silver nitrate, 247, 273, 509, 512
organic salts of, 510
Simple dressing, 527
extraction, 417, 553
hyperopic astigmatism, 173
myopic astigmatism, 173
ulcer of cornea, 276
Simulated amblyopit, 403
Sinclair, A. H. H., 586
Sinuses adjoining orbit, 476
Sketches, 21
Skiascopy, 134, 140, 163, 172, 180
Slit, stenopaic, 175, 183
Slitting canaliculus, 540
Sloughing ulcer of cornea, 278, 279
Small-pox, 241, 281, 578
Smarting, 51, 239
Smith, H., 594
Smith, Priestley, 591, 594
Smoked glasses, 501
Snell, S., 587, 589
Snellen, H., 594
Snellen's test-type, 27
Snow-blindness, 358
Sodium chlorid, 511
ethylate, 461
Solid applications to conjunctiva,
506
Solutions, 507, 513, 515, 519
Somnoform, 514
Souter, W. N., 586
Spasm, nodding, 235
of ciliary muscle, 149, 333
of retinal arteries, 374
Spasmus nutans, 235
Spastic squint, 234
Spatula, corneal, 550
Spectacles, 189
Speculum, eye, 526
Sphenoidal disease, 389, 478
Spherocylindrical lenses, 164
Spiller, W. G., 585
Spinal disease, 393, 568, 569
Sponging, 527
Spratt, C. N., 588
Spring catarrh, 250
Spud, corneal, 545
Squint, 192
alternating, 218, 220
auiblyopia with, 198
causes of, 198, 204
comitant, 200, 203, 214, 222
concomitant. See Comitant.
constant, 222
controlled reading in, 224
convergent, 200, 222
diagnosis of, 199, 206, 210, 219
divergent, 200, 218
fusion training, 221
intermittent, 218
measurement of, 201
monolateral, 220
operations, 222, 233, 543
paralytic, 200, 203, 204, 214
prognosis, 224
spastic, 234
treatment of, 212, 221, 223, 231
use of deviating eye, 221
varieties of, 203, 204
vertical, 200, 219
Stains for bacteria, 67
Staudish, Myles, 588
Staphylococcus, 238, 288
Staphyloma, 162, 305, 313, 548
Stellwag's sign, 472
Stenopaic slit, 175, 183
spectacles, 188
Stereoscope, 224, 404
Stereoscopic effect, 195
Stephenson, S., 588, 589, 593
Stevens, E. W., 588
Stevenson, M. D., 586
Stevens's phorometer, 230
Stillicidium lacrimarum, 462
Stinging pain, 52
Stirling, A. W., 591
Stovain, 515
Strabismus. See Squint.
Strength of lens, 115, 118
of prism, 110
Streptococcus, 238
Striate keratitis, 298
Stricture, lacrimal, 465, 542
Struma, 575
Strychnin, 521
Sturm, focal interval of, 170
Stye, 450
Styptics, 503, 520, 529
Subconjunctival injections, 296,
348,507
INDEX.
613
Subhyaloid hemorrhage, 90, 360
Subjective symptoms, 44
Subluxatiou of lens, 425
Suction-operation, 419, 557
Suker, G. F., 589, 592, 593
Sulphate of copper, 511
of zinc, 512
Sunburn of conjunctiva, 272
Sunlight, direct, use of, 143
Superior oblique, 209, 210
rectus, 208, 210
Supplementary lenses, 120
Suppression of image, 198
Suppurating ulcer of cornea, 278,
547
Suprarenal extract, 520, 529
Surface of cornea, 17
Sursumduction, 192, 231
Sursumvergence, 192
Swanzy, H. E., 586
Sweet, W. M., 491
Swelling of conjunctiva, 239
of lens, 411, 445, 490
of lids, 64, 250, 259, 459
of optic disk, 95
Swollen cataract, 411, 445, 496
Symblepharon, 269, 538
Sympathetic amblyopia, 334, 341
inflammation, 334, 488
irritation, 334, 337, 340
nerve, excision of cervical, 441
neurosis, 340
ophthalmia, 333, 488
Sympathizing eye, 334
Synchisis, 428
Synechia, 71, 76, 293, 316, 326, 328
Syphilis, 18, 101, 212, 214, 268, 292,
295, 311, 324, 348, 369, 377,
390, 445, 467, 475, 575
Syringing, 540
Systemic remedies, 520
TABES dorsalis, 568
Tables, 105, 112, 118, 126, 134, 146
Tangent of angle of squint, 201
Tannin, 512
Tapping sheath of optic nerve, 390
Tarsal cyst, 459
Tarsitis, 450
Tarsorrhaphy, 533
Tattooing the cornea, 304, 308, 548
Tay's choroiditis, 374
Tear-stone, 464
Telangiectasis, 460
Temperature of cornea, 275
Temporal hemianopsia, 37
Temporary amblyopia, 403
hemiauopsia, 38, 42
myopia, 158
scotoma, 42
Tenonitis, 470
Tenotomy, 214, 222, 234, 543
extended, 544
Tension, iutra-ocular, 19, 432, 434,
447
Test cards, 28
colors, 49
lenses, 119, 152, 183
letters, 27, 28, 30
objects, 26, 34
types, 27, 405
Tests of astigmatism, 178, 184
of malingering, 404
of monocular vision, 32
of ocular movements, 57
of ocular tension, 434
of scotoma, 40
of visual field, 34
of vision, 26,29
Tetany, 569
Theobald, S., 541
Therapeutics. 500
Thiersch grafting, 266, 270, 535
Thomas, C. H., 542
Thompson, A. H., 590
Thomson, Wm., 175, 176
Thoriugton, J., 586
Thrombosis of cavernous sinus. 469
of retinal vessels, 376
Tinea tarsi, 449
Tobacco amblyopia, 397
Tortuous retinal vessels, 92
Total astigmatism, 180
hyperopia, 149
synechia, 328
Toxic amblyopias, 397
diagnosis, 398, 402
treatment, 399, 402
Trachoma, 256, 539
granules, 257
Trachomatous keratitis, 298
Transient amblyopia. 403
hemianopsia, 38, 42
Transillumination, 77, 476, 477
Transparency of media, 21
Transplantation of cornea, 304
of epithelial grafts, 535, 538
of pterygium, 266, 538
Traumatic cataract, 482, 489
cycloplegia, 481
edema of retina, 483
iridoplegia, 481
614
INDEX,
Traumatism. See Injuries.
Tremulous iris, 332, 423
Trial-frames, 168
Trial-set, 119
Tricbiasis, 454, 529
Trifacial disease, 569
Trikresol, 508
True image, 196, 207
seotoina, 39
Tuberculosis of choroid, 352, 575
of conjunctiva, 268, 575
of iris, 330, 575
of skin, 461
Tumors, iutra-ocular, 330, 350, 380
of conjunctiva, 271
of iris, 330, 408
of lacrimal gland, 488
of lids, 459
of optic nerve, 396
of orbit, 459
Turbinals, hypertrophy of, 465
Twitching of lids, 129, 457
Typhoid fever, 580
Typhus fever, 580
ULCERS of cornea, 244, 276, 278,
286, 546
Unequal pupils, 75
Union of lids, 458, 533
Uremia, 365, 573
Use of trial-set, 119
Uveal tract, 313
Uveitis, 314, 334
VACCINIA, 461, 579
Vail, D. T., 593
Valk, F., 587
Variable prism, 231
squint, 218
Varicella, 379
Variola, 378
Vascular disease, 365, 374, 573
tumor, 332, 460
Veasey, C. A., 593
Venous hyperemia, 63
Vernal conjunctivitis, 255
Vertical nystagmus, 235
squint, 208, 209, 219
Vertigo, 227, 568
Virtual focus, 114
Vision, 104, 147
acuteness of, 20, 21, 25, 30, 387
Visual angle, 25
centers, 32, 37, 46, 383
field, 23, 33, 373, 377, 391, 437
443, 498
Visual lines, 192
plane, 192, 219
sensations, 44
tract, 73, 383
zone, 186
Vitiligoidea, 453
Vitreous, air-bubbles in, 497
blood-vessels in, 429
detachment of, 429
diseases of, 426
fluid, 428
foreign body in, 496
hemorrhage into, 429, 482, 497
humor, 426
inflammation, 429
membranes in, 427
opacity, 82, 83, 160, 335, 370,
427
parasites in, 429
prolapse of, 499, 556
wounds of, 491, 496
WARTS, 453
Washing conjunctiva, 505
Watered-silk retina, 89
Watery eye, 462
Waves of 'light, 104
Wearing of glasses, 189
Wecker, L. de, 304
Weeks, J. E., 241, 591, 592, 594
Weiss' reflex, 89, 162 .
Wenzel's extraction, 329, 557
Wernicke's reaction of pupil, 75
Whooping-cough, 271, 579
Wilder, W. H., 589, 591
Wilson, F. M., 594
Winking, excessive, 457
test, 54
Wood, C. A., 585, 589, 590
Wood alcohol, 400
Woodruff, T. A., 589
Woods, Hiram, 589, 593
Wootton, H. W., 594
Word-blindness, 571
congenital, 406
Working distance, 147
Worth, C., 587
Worth's arnblyoscope, 221
Wound of ciliary body, 488
of conjunctiva, 487
of cornea, 487
Wounds of eyeball, 342
of iris, 488
of lens, 489
of lids, 485
of orbit, 486
INDEX.
615
Wounds of sclera, 488
of vitreous, 491
Wiirdemaan, H. V., 593
XANTHELASMA, 453
Xerosis bacillus, 252
of conjunctiva, 268
X-rays, 492, 496
YELLOW fever, 581
Yellow oxid of mercury, 264, 513
spot, 43, 88
ZENTMAYER, W., 589
Zinc chlorid, 511
ointment, 514
sulphate, 512
Zona, 452
Zone, pericorneal, 315, 494
Zoster, ophthalmic, 287, 292, 452
SAUNDERS' BOOKS
Nervous and Mental
Diseases, Children,
Hygiene, Nursing', and
Medical Jurisprudence
W. B. SAUNDERS COMPANY
925 Walnut Street PhUadelphia
9, Henrietta Street Covent Garden, London
THE SUPERIORITY OF SAUNDERS' TEXT-BOOKS
In a recent series of articles entitled
"WHAT ARE THE BEST MEDICAL TEXT-BOOKS?"
a well known medical journal compiled a tabulation of the
text-books recommended in those schools which are mem-
bers of the American Association of Medical Colleges.
The text-books were divided into twenty (20) subjects and
under each subject was given a list of the various books
with the number of times each book is recommended.
Saunders' books head ten (10) of the twenty (20) subjects,
the largest number headed by any other publishing house
being three (3). In other words, Saunders' books lead in as
many subjects as the books of all the other publishers combined.
A Complete Catalogue of Our Publications will be Sent upon Request
SAUNDERS' BOOKS ON
Peterson and Haines'
Legal Medicine & Toxicology
A Text-Book of Legal Medicine and Toxicology. Edited
by FREDERICK PETERSON, M. D., Clinical Professor of Psychi-
atry, Columbia University (College of Physicians and Surgeons),
New York; and WALTER S. HAINES, M. D., Professor of
Chemistry, Pharmacy, and Toxicology, Rush Medical College,
in affiliation with the University of Chicago. Two imperial
octavo volumes of about 750 pages each, fully illustrated. Per
volume: Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net.
Sold by Subscription.
BOTH VOLUMES NOW READY
The object of the present work is to give to the medical and legal profes-
sions a comprehensive survey of forensic medicine and toxicology in moderate
compass. An interesting and important chapter is that on " The Destruction
and Attempted Destruction of the Human Body by Fire and Chemicals." A
chapter not usually found in works on legal medicine is that on "The
Medicolegal Relations of the X-Rays." This section will be found of unusual
importance. The responsibility of pharmacists in the compounding of pre-
scriptions, in the selling of poisons, in substituting drugs other than those
prescribed, etc., furnishes a chapter of the greatest interest. Also included in
the work is the enumeration of the laws of the various states relating to the
commitment and retention of the insane.
OPINIONS OF THE MEDICAL PRESS
Medical News, New York
" It not only fills a need from the standpoint of timeliness, but it also sets a standard
of what a text-book on Legal Medicine and Toxicology should be."
Columbia Law Review
" For practitioners in criminal law and for those in medicine who are called upon to give
court testimony in any of its various forms . . . il is extremely valuable."
Pennsylvania Medical Journal
" If the excellence of this volume is equaled by the second, the work will easily take
rank as the standing text-book on Legal Medicine and Toxicology."
NERVOUS AND MENTAL DISEASES.
Church and Peterson's
Nervous and Mental Diseases
Nervous and Mental Diseases. By ARCHIBALD CHURCH,
M.D., Professor of Nervous and Mental Diseases and Head of
Neurologic Department, Northwestern University Medical School,
Chicago ; and FREDERICK PETERSON, M. D. , Clinical Professor
of Neurology and Psychiatry in Columbia University, New York.
Octavo, 937 pages, with 341 illustrations. Cloth, $5.00 net;
Sheep or Half Morocco, $6.00 net.
JUST ISSUED-NEW (5th) EDITION
This work has met with a most favorable reception from the profession at
large. It fills a distinct want in medical literature, and is unique in that it
furnishes in one volume practical treatises on the two great subjects of neu-
rology and Psychiatry. In preparing this edition Dr. Church has carefully
revised his entire section, placing it in accord with the most recent psychiatric
advances. In Dr. Peterson's section — Mental Diseases — the Krsepelin clas-
sification of insanity has been added to the chapter on classifications for pur-
poses of reference, and new chapters on Manio- Depressive Insanity and on
Dementia Praecox included. A number of the illustrations have been replaced
by newer and better ones.
OPINIONS OF THE MEDICAL PRESS
American Journal of the Medical Sciences
" This edition has been revised, new illustrations added, and some new matter, and really
is two books. . . . The descriptions of disease are clear, directions as to treatment definite,
and disputed matters and theories are omitted. Altogether it is a most useful text-book."
Journal of Nervous and Mental Diseases
" The best text-book exposition of this subject of our day for the busy practitioner. . . .
The chapter on idiocy and imbecility is undoubtedly the best that has been given us in any
work of recent date upon mental diseases. The photographic illustrations of this part of
Dr. Peterson's work leave nothing to be desired."
New York Medical Journal
" To be clear, brief, and thorough, and at the same time authoritative, are merits that
ensure popularity. The medical student and practitioner will find in this volume a ready
and reliable resourc*."
SAUNDERS? BOOKS ON
Fruhwald and Westcott's
Diseases of Children
Diseases of Children. A Practical Reference Book for
Students and Practitioners. By PROFESSOR DR. FERDINAND
FRUHWALD, of Vienna. Edited, with additions, by THOMPSON
S. WESTCOTT, M. D., Associate in Diseases of Children, Uni-
versity of Pennsylvania. Octavo volume of 533 pages, contain-
ing 176 illustrations. Cloth, $4.50 net.
JUST READY
This worjc represents the author's twenty years' experience. Intended as
a practical reference work, the individual diseases have been arranged
alphabetically. The prophylactic, therapeutic, and dietetic treatments are
elaborately discussed.
E. H. Hartley. M. D.
Professor of Pediatrics, Chemistry, and Toxicology, Long Island College Hospital.
"It is a new idea, which ought to become popular because of the alphabetic arrange-
ment. Its title expresses just what it is — a ready reference handbook."
Ruhrah's
Diseases of Children
A Manual of Diseases of Children. By JOHN RUHRAH,
M. D., Clinical Professor of Diseases of Children, College of
Physicians and Surgeons, Baltimore. i2mo of 404 pages, fully
illustrated. Flexible leather, $2.00 net.
JUST READY
In writing this manual Dr. Ruhrah's aim was to present a work that
would be of the greatest value to students. All the important facts are given
concisely and explicitly, the therapeutics of infancy and childhood being
outlined very carefully and clearly. There are also directions for dosage and
prescribing, and a number of useful prescriptions are included. The feeding
of infants is given in detail, and the entire work is amply illustrated with
practical illustrations.
INSANITY AND HYGIENE.
Brower & Bannister on
Insanity
A Practical Manual of Insanity. For the Student and
General Practitioner. By DANIEL R. BROWER, A. M., M. D.,
LL. D., Professor of Nervous and Mental Diseases in Rush
Medical College, in affiliation with the University of Chicago ;
and HENRY M. BANNISTER, A. M., M. D., formerly Senior
Assistant Physician, Illinois Eastern Hospital for the Insane.
Handsome octavo of 426 pages, with a number of full-page
inserts. Cloth, $3.00 net.
This work, intended for the student and general practitioner, is an intel-
ligible, up-to-date exposition of the leading facts of psychiatry, and will be
found of invaluable service, especially to the busy practitioner unable to
yield the time for a more exhaustive study.
Americ&n Medicine
" Commends itself for lucid expression in clear-cut English. . . . Treatment is one of
the best features of the book, and for this aspect is especially commended."
Bergey's Hygiene
The Principles of Hygiene: A Practical Manual for Stu-
dents, Physicians, and Health Officers. By D. H. BERGEY,
A. M., M. D., Assistant Professor of Bacteriology, University of
Pennsylvania. Octavo of 536 pages, illust. Cloth, $3.00 net.
RECENTLY ISSUED— SECOND REVISED EDITION
This book is intended to meet the needs of students of medicine in the
acquirement of a knowledge of those principles upon which modern hygienic
practices are based, and to aid physicians and health officers in familiarizing
themselves with the advances made in hygiene and sanitation in recent years.
Buffalo Medical Journal
" It will be found of value to the practitioner of medicine and the practical sanitarian;
and students of architecture, who need to consider problems of heating, lighting, ventila-
tion, water supply, and sewage disposal, may consult it with profit."
SAUNDERS' BOOKS ON
GET Afn*»rir*an THE NEW
THE BEST /imeriCan STANDARD
Illustrated Dictionary
Just Issued— New (4th) Edition
The American Illustrated Medical Dictionary. A new
and complete dictionary of the terms used in Medicine, Surgery,
Dentistry, Pharmacy, Chemistry, and kindred branches; with
over 100 new and elaborate tables and many handsome illustra-
tions. By W. A. NEWMAN BORLAND, M. D., Editor of " The
American Pocket Medical Dictionary. ' ' Large octavo, 850 pages,
bound in full flexible leather. Price, $4.50 net; with thumb
index, $5.00 net.
Gives & Maximum Amount of Matter in a Minimum Space, and at the
Lowest Possible Cost
WITH 2000 NEW TERMS
The immediate success of this work is due to the special features that
distinguish it from other books of its kind. It gives a maximum of matter
in a minimum space and at the lowest possible cost. Though it is practi-
cally unabridged, yet by the use of thin bible paper and flexible morocco
binding it is only i%" inches thick. In this new edition the book has
been thoroughly revised, and upward of two thousand new terms have
been added, thus bringing the book absolutely up to date. The book con-
tains hundreds of terms not to be found in any other dictionary, over IOO
original tables, and many handsome illustrations.
PERSONAL OPINIONS
Howard A. Kelly, M. D.,
Professor of Gynecology, Johns Hopkins University, Baltimore.
" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such conve-
nient size. No errors have been found in my use of it."
Roswell Park, M. D.,
Professor of Principles and Practice of Surgery and of Clinical Surgery, University
of Buffalo.
" I must acknowledge my astonishment at seeing how much he has condensed within
relatively small space. I find nothing to criticize, very much to commend, and was inter-
ested in finding some of the new words which are not in other recent dictionaries."
PERSONAL HYGIENE.
Galbraith's
Four Epochs qf Woman's Life
Second Revised Edition — Recently Issued
The Four Epochs of Woman's Life : A Study in Hygiene.
By ANNA M. GALBRAITH, M. D., Fellow of the New York Acad-
emy of Medicine, etc. With an Introductory Note by JOHN H.
MUSSER, M. D., Professor of Clinical Medicine, University of
Pennsylvania. i2mo volume of 247 pages. Cloth, $1.50 net.
In this instructive work are stated, in a modest, pleasing, and conclusive
manner, those truths of which every woman should have a thorough knowl-
edge. Written, as it is, for the laity, the subject is discussed in language
readily grasped even by those most unfamiliar with medical subjects.
Birmingham Medical Review, England
" We do not as a rule care for medical books written for the instruction of the public.
But we must admit that the advice in Dr. Galbraith's work is in the main wise and whole-
Pyle's Personal Hygiene
A Manual of Personal Hygiene : Proper Living upon a
Physiologic Basis. By Eminent Specialists. Edited by WALTER
L. PYLE, A. M., M. D., Assistant Surgeon to Wills Eye Hospital,
Philadelphia. Octavo volume of 441 pages, fully illustrated.
Cloth, $1.50 net.
NEW (ad) EDITION— RECENTLY ISSUED
In this new second edition there have been added new chapters on Home
Gymnastics and Domestic Hygiene, besides an Appendix of Emergency Pro-
cedures.
Boston Medical and Surgical Journal
" The work has been excellently done, there is no undue repetition, and the writer* have
succeeded unusually well in presenting facts of practical significance based on sound
knowledge."
SAUNDERS* BOOKS ON
Draper's Legal Medicine
A Text-Book of Legal Medicine. By FRANK WINTHROP
DRAPER, A. M., M. D., Professor of Legal Medicine in Harvard
University, Boston. Handsome octavo of 573 pages, illustrated.
Cloth, $4.00 net.
RECENTLY ISSUED
The author of this work has had twenty-six years' experience as Medical
Examiner for the city of Boston, his investigations comprising nearly eight
thousand deaths under a suspicion of violence.
Hon. Olin Bryan, LL. B.
Professor of Medical Jurisprudence , Baltimore Medical College
" It is comprehensive, thorough, and must, of a necessity, prove a splendid acquisition
to the libraries of those who are interested in medical jurisprudence."
Jakob and FisherV
Nervous System and its Diseases
Atlas and Epitome of the Nervous System and its
Diseases. By PROFESSOR DR. CHR. JAKOB, of Erlangen. From
the Second Revised German Edition. Edited, with additions, by
EDWARD D. FISHER, M. D., Professor of Diseases of the Nervous
System, University and Bellevue Hospital Medical College, New
York. With 83 plates and copious text. Cloth, $3.50 net. In
Saunders1 Hand-Atlas Series.
The matter is divided into Anatomy, Pathology, and Description of Dis-
eases of the Nervous System. The plates illustrate these divisions most
completely ; especially is this so in regard to pathology. The exact site and
character of the lesion are portrayed in such a way that they cannot fail to
impress themselves on the memory of the reader.
Philadelphia Medical Journal
" We know of no one work of anything like equal size which covers this important and
complicated field with the clearness and scientific fidelity of this hand-atlas."
DISEASES OF CHILDREN.
American Text-Book of
Diseases of Children
American Text-Book of Diseases of Children. Edited
by Louis STARR, M. D., Consulting Pediatrist to the Maternity
Hospital, etc. ; assisted by THOMPSON S. WESTCOTT, M. D.,
Attending Physician to the Dispensary for Diseases of Children,
Hospital of the University of Pennsylvania. Handsome octavo,
1244 pages, profusely illustrated. Cloth, $7.00 net; Sheep or
Half Morocco, $8.00 net.
SECOND REVISED EDITION
To keep up with the rapid advances in the field of pediatrics, the whole
subject-matter embraced in the first edition has been carefully revised, new
articles added, some original papers amended, and a number entirely rewrit-
ten and brought up to date.
British Medical Journal
" May be recommended as a thoroughly trustworthy and satisfactory guide to the subject
of the diseases of children."
Paul's Fever Nursing'
Nursing in the Acute Infectious Fevers. By GEORGE P.
PAUL, M.D., Assistant Visiting Physician to the Samaritan Hos-
pital, Troy, N. Y. i2mo of 200 pages. Cloth, #1.00 net.
JUST ISSUED
Dr. Paul has written his book especially for the trained nurse, so that all
extraneous matter has been studiously avoided. Great stress has been laid
upon care and management in each disease, as this relates directly to the
duties of the nurse. The work discusses fever in general, then each acute
infectious fever separately, and finally those practical procedures necessary to
the proper management of the fevers described.
SAUNDERS' BOOKS ON
Friedenwald & Ruhrah's
Dietetics for Nurses
Dietetics for Nurses. By JULIUS FRIEDENWALD, M. D.,
Clinical Professor of Diseases of the Stomach, College of Physi-
cians and Surgeons, Baltimore; and JOHN RUHRAH, M. D.,
Clinical Professor of Diseases of Children, College of Physicians
and Surgeons, Baltimore. 1 2mo of 363 pages. Cloth, $1.50 net.
JUST ISSUED
This work has been prepared to meet the needs of the nurse, both in the
training school and after graduation. Rectal alimentation and the feeding
of operative cases are fully described.
Edinburg Medical Journal.
" It appears to us to contain all the practical side of dietetics, of bandy size and devoid
of padding."
Lewis' Anatomy and
Physiology for Nurses
Anatomy and Physiology for Nurses. By LsRoy LEWIS
M. D., Surgeon to and Lecturer on Anatomy and Physiology for
Nurses at the Lewis Hospital, Bay City, Michigan. 12010 of 317
pages, with 146 illustrations. Cloth, $1.75 net.
JUST ISSUED
The author has based the plan and scope of the work on the methods he
has employed in teaching the subjects, and has made the text unusually
simple and clear. The object was so to deal with anatomy and physiology that
the student might easily grasp the primary principles, at the same time laying
a broad foundation for a wider study.
NURSING.
De Lee's Obstetrics for Nurses
Obstetrics for Nurses. By JOSEPH B. DE LEE, M. D., Pro-
fessor of Obstetrics in the Northwestern University Medical School,
Chicago ; Lecturer in the Nurses' Training Schools of Mercy,
Wesley, Provident, Cook County, and Chicago Lying-in Hos-
pitals. i2mo of 460 pages, fully illustrated. Cloth, $2.50 net.
JUST ISSUED— NEW(2nd) EDITION
The illustrations in Dr. De Lee's work are nearly all original, and repre-
sent photographs taken from actual scenes. The text is the result of the
author's eight years' experience in lecturing to nurses.
J. Clifton Edgar, M. D.,
Professor of Obstetrics and Clinical Midwifery, Cornell University, New York.
" It is far and away the best that has come to my notice, and I shall take great pleasure
in recommending it to my nurses, and students as well."
Davis' Nursing
Obstetric and Gynecologic Nursing. By EDWARD P.
DAVIS, A. M., M. D., Professor of Obstetrics, Jefferson Medical
College, Phila. i2mo, 400 pages, illustrated. Buckram, $1.75 net.
RECENTLY ISSUED— SECOND REVISED EDITION
The Lancet, London
" Not only nurses, but even newly qualified medical men, would learn a great deal by a
perusal of this book. It is written in a clear and pleasant style, and is a work we can
recommend."
Beck's Reference Handbook
for Nurses
A Reference Handbook for Nurses. By AMANDA K. BECK,
Chicago. i2mo of 150 pages. Flexible morocco, $1.25 net.
RECENTLY ISSUED
This little book contains information upon every question that comes to a
nurse in her daily work, and embraces all the information that she requires to
carry out any directions given by the physician.
Boston Medical and Surgical Journal
" Must be regarded as extremely useful, not only for nurses, but for physicians."
SAUNDERS* BOOKS ON
Hofmann and Peterson's
Legal Medicine
Atlas of Legal Medicine. By DR. E. VON HOFMANN, of
Vienna. Edited by FREDERICK PETERSON, M. D. , Clinical Profes-
sor of Psychiatry in the College of Physicians and Surgeons, New
York. With 120 colored figures on 56 plates, and 193 half-tone
illustrations. Cloth $3.50 net. In Saunders1 Hand-Atlas Series.
By reason of the wealth of illustrations and the fidelity of the colored
plates, the book supplements all the text-books on the subject. Moreover,
it furnishes to every physician, student, and lawyer a veritable treasure-house
of information.
The Practitioner, London
" The illustrations appear to be the best that have ever been published in connection
with this department of medicine, and they cannot fail to be useful alike to the medical jurist
and to the student of forensic medicine."
Chapman's
Medical Jurisprudence
Medical Jurisprudence, Insanity, and Toxicology. By
HENRY C. CHAPMAN, M. D., Professor of Institutes of Medicine
and Medical Jurisprudence in Jefferson Medical College, Phila-
delphia. Handsome i2mo of 329 pages, fully illustrated. Cloth,
$1.75 net.
RECENTLY ISSUED— THIRD REVISED EDITION, ENLARGED
This third edition has been thoroughly revised and greatly enlarged, so as
tc bring it absolutely in accord with the very latest advances in this important
branch of medical science.
Medical Record, New York
"The manual is essentially practical, and is a useful guide for the general practitioner,
besides possessing literary merit."
NURSING.
Golebiewski and Bailey V
Accident Diseases
Atlas and Epitome of Diseases Caused by Accidents.
By DR. ED. GOLEBIEWSKI, of Berlin. Edited, with additions, by
PEARCE BAILEY, M. D., Consulting Neurologist to St. Luke's
Hospital, New York. With 71 colored illustrations on 40 plates,
143 text-illustrations, and 549 pages of text. Cloth, $4.00 net.
In Saunders1 Hand-Atlas Series.
This work contains a full and scientific treatment of the subject of accident
injury ; the functional disability caused thereby ; the medicolegal questions
involved, and the amount of indemnity justified in given cases.
The Medical Record, New York
"This volume is upon an important and only recently systematized subject, which is
growing in extent all the time. The pictorial part of the book is very satisfactory."
StoneyV
Materia Medica for Nurses
Practical Materia Medica for Nurses, with an Appendix
containing Poisons and their Antidotes, with Poison-Emergencies ;
Mineral Waters ; Weights and Measures, etc. By EMILY M. A.
STONEY, Superintendent of the Training School for Nurses at the
Carney Hospital, South Boston, Mass. 1 2mo, 300 pages. $1.50 net.
JUST ISSUED— NEW (3rd) EDITION
In this work the consideration of the drugs includes their names, their
sources and composition, their various preparations, physiologic actions,
directions for handling and administering, and the symptoms and treatment
of poisoning.
Journal of the American Medical Association
" So far as we can see, it contains everything that a nurse ought to know in regard to
drug*. At a reference-book for nurses it will without question be very useful."
14 SAUNDERS' BOOKS ON
StoneyV Nursing
Practical Points in Nursing : for Nurses in Private Practice.
By EMILY M. A. STONEY, Superintendent of the Training
School for Nurses at the Carney Hospital, South Boston, Mass.
466 pages, fully illustrated. Cloth, £1.75 net.
THIRD REVISED EDITION— RECENTLY ISSUED
In this volume the author explains the entire range of private nursing as
distinguished trom*hospital nursing, and the nurse is instructed how best to
meet the various emergencies of medical and surgical cases when distant
from medical or surgical aid or when thrown on her own resources. An
especially valuable feature will be found in the direction how to improvise
everything ordinarily needed in the sick-room.
The Lancet, London
"A very complete exposition of practical nursing in its various branches, including
obstetric and gynecologic nursing. The instructions given are full of useful detail."
Stoney's Technic for Nurses
Bacteriology and Surgical Technic for Nurses. By
EMILY M. A. STONEY, Superintendent of the Training School,
Carney Hospital, South Boston. Revised by FREDERIC R. GRIF-
FITH, M. D., Surgeon, N. Y. i2mo, 278 pages, illus. $ 1.50 net.
RECENTLY ISSUED— NEW (2d) EDITION
Spratling on Epilepsy
Epilepsy and Its Treatment. By WILLIAM P. SPRATLING,
M. D., Medical Superintendent of the Craig Colony for Epilep-
tics, Sonyea, New York. Octavo of 522 pages, fully illustrated.
Cloth, |4.oo net.
CHILDREN AND HYGIENE. 15
Griffith'./-
Care of the Baby
The Care of the Baby. By J. P. CROZER GRIFFITH, M. D.,
Clinical Professor of Diseases of Children, University of Penn-
sylvania. i2mo, 436 pages. Illustrated. Cloth, $1.50 net.
RECENTLY ISSUED— THIRD EDITION, REVISED
New York Medical Journal
" We are confident if this little work could find its way into the hands of every trained
nurse and of every mother, infant mortality would be lessened by at least fifty per cent."
Crothers' Morphinism
Morphinism and Narcomania from Opium, Cocain, Ether,
Chloral, Chloroform, and other Narcotic Drugs ; also the Etiol-
ogy, Treatment, and Medicolegal Relations. By T. D. CROTH-
ERS, M. D., Superintendent of Walnut Lodge Hospital, Hartford,
Conn. Handsome i2mo of 351 pages. Cloth, $2.00 net.
The Lancet, London
" An excellent account of the various causes, symptoms, and stages of morphinism, the
discussion being throughout illuminated by an abundance of facts of clinical, psychological,
and social interest."
Abbott's
Transmissible Diseases
The Hygiene of Transmissible Diseases: Their Causa-
tion, Modes of Dissemination, and Methods of Prevention. By
A. C. ABBOTT, M. D., Professor of Hygiene and Bacteriology,
University of Pennsylvania. Octavo, 35 1 pages, with numerous
illustrations. Cloth, $2.50 net.
SECOND REVISED EDITION
The Lancet, London
" We heartily commend the book as a concise and trustworthy guide in the subject with
which it deals, and we sincerely congratulate Professor Abbott."
1 6 SAUNDERS' BOOKS ON NURSING.
American Pocket Dictionary 4th Ed.— Recently issued
AMERICAN POCKET MEDICAL DICTIONARY. Edited by W. A.
NEWMAN BORLAND, M. D., Assistant Obstetrician to the Hospital of
the University of Pennsylvania. Containing the pronunciation and defi-
nition of the principal words used in medicine and kindred sciences,
with 64 extensive tables. Handsomely bound in flexible Isalher, with
gold edges, $1.00 net; with patent thumb index, $1.25 net.
Morrow's Immediate Care of Injured Just Ready
IMMEDIATE CARE OF THE INJURED. By ALBERT S. MORROW, M. D.,
Attending Surgeon to the New York City Hospital for the Aged and In-
firm. Octavo of 350 pages, with 250 illustrations. Cloth, $2.50 net.
Dr. Morrow's book on emergency procedures is written in a definite and decisive
style, the reader being told just what to do in every emergency. It is a practical book
. for every day. use, and the large number of excellent illustrations can not but make the
treatment to be pursued in any case clear and intelligible. Physicians and nurses will
find it indispensiblf. '
Starr's Diets for Infants and Children
DIETS SFOR INFANTS AND CHILDREN IN HEALTH AND IN DISEASE.
By Louis STARR, M. D., Consulting Pediatrist to the Maternity Hospi-
tal, Philadelphia. 230 blanks (pocket-book size). Bound in flexible
Morocco, $1.25 net.
Grafstrom's Mechano-Therapy
A TEXT-BOOK OF MECHANO-THERAPY (Massage and Medical Gym-
nastics). By AXEL V. GRAFSTROM, B. Sc., M.D., Attending Physician
to the Gustavus Adolphus Orphanage, Jamestown, New York. I2mo,
200 pages, illustrated. Cloth, $1.25 net.
Shaw on Nervous Diseases and Insanity
Recently Issued — Fourth Edition, Revised
ESSENTIALS OF NERVOUS DISEASES AND INSANITY : their Symptoms and
Treatment. A Manual for Students and Practitioners. By the late JOHN
C. SHAW, M. D., Clinical Professor of Diseases of the Mind and Nervous
System, Long Island College Hospital, New York. 121110 of 204 pages,
illustrated. Cloth, $l.oo net. In Saunders1 Question- Compend Series.
Powell's Diseases of Children 3d Edition, Revised
ESSENTIALS OF THE DISEASES OF CHILDREN. By WILLIAM M.
POWELL, M. D. Revised by ALFRED HAND, JR., A. B., M. D., Dis-
pensary Physician and Pathologist to the Children's Hospital, Philadel-
phia. I2ino volume of 259 pages. Cloth, $1.00 net. In Saunder?
Question- Compend Series.
V
JJ
BQi
University of Toronto
Library
DO NOT
REMOVE
THE
CARD
FROM
THIS
POCKET
Acme Library Card Pocket
Under Pat "Ref . Index File"
Made by LIBRARY BUREAU
Live Music Archive
Librivox Free Audio
Metropolitan Museum
Cleveland Museum of Art
Internet Arcade
Console Living Room
Books to Borrow
Open Library
TV News
Understanding 9/11