Paresis Musculi Ciliaris.- Paralysis of the Accommodation.- This may be either either partial or complete, and the cause may be either local or general. If but one eye is affected, the cause is more apt to be local, affecting the third nerve in some part of its course, and the primary cause may be syphilis. Some injury of the eye or orbit may cause it, through some reflex influence, as may also some irritation of the fifth nerve, as in decayed teeth, etc. Exposure to draughts of air may also cause a one- sided paralysis of the accommodation. When the paresis affects the ciliary muscle of both eyes the cause is more apt to the general and often from some constitutional disorder. The most frequent cause is diphtheria and comes on usually during convalescence or some time after. Paralysis of the accommodation is also seen after fevers, such as typhoid and recurrent fever. It also occurs in diabetes, articular rheumatism, locomotor ataxia, after debilitating excesses, as masturbation, sexual indulgence, etc. It is sometimes found due to uterine disease and from syphilis. Exposure to draught is a very frequent cause, and it has often been seen following la grippe. It is also present with paralysis of the external muscles in total paralysis of the third nerve.
The diagnosis of paralysis of the ciliary muscle depends upon the one constant symptom, viz., the diminution or complete abolition of the amplitude of accommodation from a recession of the near point. This will always be suspected in subjects who formerly had good vision for near objects, bur find they can only see well at a distance. The pupil will usually, at the same time, be dilated, though frequently there will be a paresis of accommodation without Mydriasis.
PROGNOSIS is, as a rule, in these cases favorable, for as the majority of cases result from diphtheria, fevers, etc., the proper treatment will effect a relief. It must be borne in mind, however, that the paralysis of the accommodation may be the forerunner of some grave general condition which may be of serious import to the life of the patient, as, for example, when due to diabetes, to some obscure cerebral or spinal disease, etc. Hence the prognosis always depends upon a correct diagnosis as to the cause of the malady.
TREATMENT.- The cause of the paralysis must be sought out and given due consideration in the treatment. As precautionary measures, all convalescents should be carefully warned of the danger of overtaxing the eyes. The use locally of Eserine or Pilocarpine, of sufficient strength to slightly contract the pupil and stimulate the accommodation, is of great value. Eserine is the most active of the two, and the best results are had from a weak solution of the sulphate. A one-tenth to one-half grain to the ounce solution, instilled once or twice a day, is sufficient and usually better than a more concentrated solution. Pilocarpine is less energetic, and a solution of from two to four grains of the muriate to the ounce may be instilled once or twice a day if any unpleasantness is experienced from the Eserine.
Galvanism should also be employed, using from two to five milliamperes, with the positive pole applied to the base of the occiput and the negative over the closed lids. The current should be applied for two or three minutes daily. Patients may also be allowed moderate use of the eyes for necessary work with the proper convex glass.
The use of the appropriate remedy will also be of much service, and attention is especially directed to Aconite, Argent. nit., Causticum, Gelsemium, Opium, Paris quad. and Physostig. See indications under Paralysis of the Ocular Muscles, page 160.
Spasmus Musculi Ciliaris.- Spasms of the Accommodation.- This may be clonic, when existing only during convergence, or during fixation for distinct vision and ceases when the eye is in repose; or tonic, when it is permanent and only yielding to mydriatics. Spasm usually affects both eyes in an equal degree, but may exist in one alone, or be of a greater degree in one eye than in the other. Spasm of the ciliary may occur in normal eyes or in any refractive error of the eyes. It causes a decease of the hypermetropia and an increase of the existing myopia. It may produce an apparent astigmatism, or conceal a real one. Patients will usually complain of an indistinctness of distant objects, while near objects are held closer to the eye than they should be, and they will have tired, trained feelings of the eyes together, with headaches upon using the eyes.
There may be in some cases a tendency to convergence of the eyes, owing to the intimate relation between accommodation and convergence. Spasm of the accommodation is frequently found in children with hypermetropia from the strain occasioned by use of the eyes; it may be produced in emmetropes from prolonged use of the eyes and in myopes from the use of too strong glasses. As other local causes we find it in injuries of the eye, in inflammation of the cornea, conjunctiva, sclera or lids. It may occur as symptomatic of affections of the central nervous system, as in epilepsy and hysteria. Spasm of the ciliary muscle may or may not be associated with contraction of the pupil. The condition occurs most frequently among asthenic subjects and more especially among young girls. The diagnosis of spasm depends upon a comparison of the apparent refraction with that which is real, as determined by an examination under the influence of a mydriatic.
TREATMENT.-In aggravated cases of spasm of the ciliary muscle the regular and prolonged use of Atropine or the constant use of convex glasses may be necessary, but usually internal medication, with rest of the eyes for near work, will suffice to diminish the spasm; after which any anomaly of refraction may be corrected.
Jaborandi.-In spasm of the accommodation, or irritability of the ciliary muscle, there is no remedy so frequently useful as this. Many cases of simulated myopia have yielded to its use. Everything at a distance is blurred without concave glasses, though near objects are seen distinctly. The vision may be constantly changing. Nausea or vertigo on using the eyes. Eyes tire easily and are irritable, especially on sewing. Twitching of the lids and pain in the eyeballs. Spasm of the internal recti muscles.
Eserine.-Dr. N.L.Macbride has pointed out the value of this drug in spasm of the accommodation, and has found it of much value in young hyperopes of slight degree, associated with headache and general asthenopic symptoms. The physiological action of Eserine is to produce an almost perfect picture of spasm of the accommodation.
Physostigma ven.-In its proving there has been developed marked spasmodic action of the ciliary muscle and muscles of the lid. It has, therefore, been used with manifest advantage in these conditions, particularly the former. The patient cannot read long on account of this spasm and must bring the book near the eyes. There is also generally to be seen twitchings in the lids and around the eyes when Physostigma is required. The pupil is contracted.
Agaricus.-In spasm of the ciliary muscle especially if associated with spasm of the lids or general chorea. Twitchings of the eyelids.
Lilium tigrinum-Spasm of the accommodation in low degrees of myopic astigmatism, when the cylindrical glasses are not worn with comfort.
Nux vomica, Puls, and Sulph. have also been used with benefit, as may any of that class of remedies denominated as antispasmodics.
Irido-choroiditis (Irido-cyclitis).-Owing to the fact that the iris, ciliary body and choroid form one continuous tissue, any inflammation involving one structure is prone to extend through the whole uveal tract. There are in irido-choroiditis, as in both iritis and cyclitis, three pathological changes that may occur, viz.: Plastic, serous and suppurative, each taking on the same changes as have already been detailed under the iris. Clinically the disease may be divided into two forms.
The first form is the result of an iritis in which there has been posterior synechiae, with exclusion of the pupil. In this pupil may remain clear, but there is soon noticed a gradual bulging forward of the iris, in one portion, in knob-like protuberances which may be confined there or extend, involving nearly the whole iris. The bulging is due to an accumulation of fluid in the posterior chamber and occurs in spots, because the inflammation of the iris has weakened the tissue at these points. The iris is discolored, its fibrillae appear stretched and its veins are enlarged and tortuous in their course. The tension soon becomes increased, but, as the disease advances toward an atrophied ball, becomes diminished. The vitreous is diffusely clouded, there is ciliary injection, considerable pain, which is usually worse at night; the eyeball very sensitive to touch and the anterior chamber is shallow, due to the bulging of the iris.
The second form of irido-choroiditis may be called a parenchymatous variety; as there is a considerable swelling and proliferation of the connective tissue, with an engorgement of the vessels throughout the whole uveal tract. There is occlusion of the pupil and gummata may be found. A false membrane, tough and tenacious, forms behind the iris and may extend back over the ciliary processes and choroid. This membrane becomes organized, adheres closely to the capsule of the lens and may undergo secondary contraction, causing possibly a rupture of the capsule of the lens or detachment of the ciliary body. In the later stages the retina may be detached and the plastic exudation on the choroid may become cartilaginous or bony.
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.