CAUSES.-It most frequently develops after some injury of the eyeball, where a foreign body has become lodged within the eye; or may occur from a slight perforation or incision in which possibly some infectious matter has been conveyed into the eye. Thus it may be set up operations-after the removal of cataracts or any opening of the bulbus, in cases of purulent or infectious conditions of the eye, as in dacryocystitis, perforating ulcers, etc. It is most often found in old people and the prognosis is always unfavorable.
As a metastatic choroiditis it may occur in two ways. First, where it is found in connection with pyaemia, puerperal fever, typhoid, variola, malignant pustule, phlegmonous erysipelas, suppurative endocarditis, acute rheumatism, etc., the immediate cause in these cases is an embolus affecting the choroidal vessels, and this embolus undoubtedly conveys the infecting micro-organism. The choroiditis, when resulting in this way, is usually confined to but one eye, although it sometimes has been found occurring in both eyes. This form is also apt to be very rapid and acute in its destructive course. The purulent infiltration occurs first between the retina and choroid and rapidly extends, involving the whole eyeball.
The second form of metastatic infection is that found following meningitis or cerebro-spinal meningitis, and in these cases it is due to the communication between the sub-arachnoid cavity of the brain and the intervaginal space of the optic nerve, forming a direct channel for the transmission of the inflammatory products to the eye. One or both eyes may be affected, although more frequently but one. In this variety the course is not usually as acute or as purulent as in the preceding from. Thrombosis of the cerebral sinuses, associated with a thrombosis of the ophthalmic veins, may also give rise to a suppurative choroiditis.
DIAGNOSIS.-Rarely we may find a very sluggish form of suppurative choroiditis with no inflammatory signs which looks so much like a glioma of the retina that it is almost impossible to differentiate between them. In both the cornea, aqueous and lens are clear, anterior chamber shallow, pupil dilated iris and lens pushed forward, with a light colored (whitish or yellow) reflex from the pupil. The chief diagnostic sign may be the tension which early will be normal in both, but soon becomes increased in glioma and decreased in choroiditis (or pseudo-glioma as it is also called). In choroiditis we may have history of previous illness. The course of the disease would of course ultimately determine the diagnosis, as choroiditis leads to atrophy of the eyeball and glioma to perforation. We should never delay too long, as early enucleation offers the only chance in glioma, and as choroiditis leads to blindness nothing is lost from an enucleation in that case.
PROGNOSIS.-In all forms of suppurative choroiditis, from what-ever cause it may arise, the prognosis is absolutely unfavorable, and when due to meningitis, pyaemia, etc., life itself is of course in danger.
TREATMENT.-Our first endeavor should be to save the eye if possible, and with this end in view any exciting cause must be removed. If it is due to a swollen, cataractous lens this must be extracted; if to an orbital abscess, this must be opened; or if a foreign body is found to be the cause, as is frequently the case, we must try to remove it, unless it is too deep within the eye, when it is far better to enucleate. In cases of metastatic origin little can be done, as the general illness will usually require our main attention. Enucleation should not be performed while the inflammatory process is very pronounced, as experience has shown that it is advisable to wait before we undertake the operation on until the severity of the symptoms has subsided; but if a foreign body is present within the ball, enucleation of the eye is strongly recommended after the inflammation has been subdued, for there is always danger of sympathetic irritation of the other eye.
Enucleation during panophthalmitis has been practiced and recommended by some. Rolland Rec. d’ophth., 1888, No. 7. has enucleated in eighty cases without a death. He, however, does not enucleate when phosphenes indicate that the lymph sheaths of the optic nerve have become affected or cerebral symptoms have manifested themselves. Andrews N. Y. Medorrhinum Jour., Dec. 29, 1888. reported twelve enucleations with no unfavorable symptoms. He also gives the statistics of thirty fatal cases, but believes the danger can be diminished by strict antiseptic precautions and care.
For the disease itself, in the first stage, cold or ice compresses may be used with advantage, but if the pain becomes very severe in and around the eye, especially if suppuration has commenced, more benefit will be gained from warm applications, either dry or moist. Atropine may be of advantage, early in palliating the pain. If the pain is very severe and the tension increased, paracentesis or an iridectomy will be found of service. If however, suppuration has so far advanced so as to destroy the eye and the pain is intense, it is best to make a deep free incision of the eyeball at once and employ hot fomentations.
A nourishing diet, even stimulants becomes necessary to sustain the patient`s strength after suppuration takes place.
Rhus tox.-The most commonly indicated remedy in panophthalmitis, whether it be of traumatic origin or not. It is useful in nearly every stage of the disease, though is particularly adapted to the first. The lids are oedematously swollen, spasmodically closed, and upon opening them a profuse gush of tears pours out. The conjunctiva is oedematous, forming a wall around the cornea, which may be slightly hazy. The iris may be swollen, pupil contracted and aqueous cloudy, while the pain in and around the eye is often severe, especially at night and upon any change in the weather.
Aconite.-First stage, accompanied by high fever and much thirst. Eyelids red, swollen, hot and dry, with much pain in the eye.
Hepar.-After suppuration has begun. Eye very sensitive to touch and the pains severe and throbbing, ameliorated by warm applications.
Phytolacca.-Panophthalmitis, especially if traumatic. Lids very hard, red and swollen; chemosis and pus in the interior of the eye. Pains quite severe.
Apis.-Lids oedematous, chemosis, stinging pains through the eye. Drowsiness and absence of thirst usually accompany the local indications.
Arsenic.-If the patient is very restless and thirsty, with oedema of the lids and conjunctiva, and severe burning pain. Arsenicum cases are similar to Rhus, though the former does not compare with the later in degree of usefulness.
Asafoet., Belladonna, Mercurius, Silicea, Sulphur and other remedies may in certain and stages be useful.
Sclerotico-Choroiditis Anterior.-In this form of choroditis there is a participation of the sclera in the inflammatory process. The disease is generally circumscribed to a portion of the sclera and choroid in the vicinity of the iris, although it may entirely surround the cornea. It is usually chronic in its nature, the most acute cases often lasting for months, while others will run for years. The appearance resembles very closely that described under episcleritis, although the pain is apt to be more severe and the inflammation and swelling of the conjunctival tissues is more general. The inflammation may extend to the iris, causing synechiae; or to the cornea, causing what has been called a sclerotising keratitis.
In the chronic form, staphyloma frequently results from a weakening of the sclera, due to the inflammation; it becomes thinned, presenting then a bluish or grayish-blue color. The staphyloma may be of varying size or shape, and occur either at the sclero-corneal margin or as far back as behind the ciliary region. This gradual bulging is a very slow process, extending often a period of years and is usually unaccompanied by much pain. It seems to occur more frequently in women than in men and is most liable to occur before adult life.
The prognosis is always unfavorable, especially in the more chronic cases, as treatment seems to be of little value. See Scleritis.
Sclerotico-Choroiditis Posterior (Sclerectasia Posterior, Staphyloma Posterior).
PATHOLOGY.-The pathological changes present in posterior staphyloma are those of an atrophic choroiditis, with a gradual thinning and atrophy of the sclera. It may have small points of exudation, especially near the macula, which have a tendency to coalesce and go on gradually to atrophy. Pigment proliferations are usually present around the edges of the crescent, especially when the condition is progressive. There may also be found fluidity and opacities in the vitreous and changes in the retina. The vitreous may be detached either at the lens or the posterior pole.
SYMPTOMS.-The disease is always found existing in myopic eyes, the eyeball is apt to appear prominent and its movements may be somewhat impaired. patients will sometimes complain of a feeling of tension in the eyes and there may be some pain in or around the eye, and tired, strained aching of the eyes when using them. In the progressive stage metamorphopsia is a most frequent symptoms, and often times complaint is made of black spots floating before the vision (muscae volitantes), of cloudy vision and subjective light sensations. An ophthalmoscopic examination will show the presence of a white crescent around the optic nerve, usually at its outer side (See Chromo-Lithograph, Plate II., Fig. 3); the size and shape of the crescent may vary greatly from a small, narrow rim at one side to a spot several times the diameter of the optic nerve.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.