Archiv. Ophthal, vol. xix., 2, 1890. reports a case that was undoubtedly of primary origin, and argues that the condition is more often primary than secondary. TREATMENT.-Fontan Rec. d’ophth., No. 10, 1886. advises scraping out the nodules and dusting iodoform upon them. The use of the galvano-cautery, as well as the knife to destroy the local products, is recommended by Knapp (loc.cit.). Internal medication, such as is used in tuberculous conditions elsewhere, should be followed. Lesions of the Conjunctiva.-Foreign bodies penetrate the conjunctiva and may cause irritation if not removed early. They are mostly found on the inner surface of the upper lid, 2 to 3 mm. from the posterior border; the shallow border between cornea and sclera; the upper fornix. If allowed to remain, they set up hyperaemia and catarrhal conjunctivitis. They should be removed. Wounds from sharp instruments, so long astreatment should be both general and local.
Anatomy.- The conjunctiva is the delicate mucous membrane lining the inner surface of the eyelids; from the lids it is reflected upon the globe and covers the sclerotic as far as the cornea, with which it becomes continuous. The conjunctiva is divided into three portions: the palpebral, covering the inner surface of the lids; the bulbar, covering the sclerotic; and the fornix, or loose folded portion connecting these two. At the cornea the conjunctiva overlaps the cornea slightly, and at this point is called the limbus conjunctiva or corneae. The bulbous portion of the conjunctiva is formed of three layers-the external epithelial layer, the fibrous tissue and the subconjunctival tissue.
The epithelial layer is formed of cylindrical cells externally and a deeper layer of smaller cells. The fibrous tissue is a fine reticulated structure, containing nucleated cells, together with a few elastic elements. The subconjunctival tissue is loose and elastic, with fibres uniting it to the sclerotic. The conjunctiva, especially the portion covering the lid and forming the cul-de-sac, contains numerous lymphatic follicles and acinous glands.
The nerve supply of the conjunctiva is very free and is derived from the fifth pair. The blood supply is also extremely abundant, especially in the region of the limbus and around the caruncle.
The function of the conjunctiva is to act as a lubricating surface.
Hyperaemia of the Conjunctiva.- In the strict sense of the word, hyperaemia is but the preliminary stage of different diseases, yet in the conjunctiva it is often the only symptom, and is, therefore, considered here as an independent condition.
SYMPTOMS.- The vessels have the appearance of a coarse network. The transparency and smoothness of the conjunctiva is lost and the papillae of the lids are more marked. The eyes are red, feel hot and heavy, and as though there was sand in them; there is smarting, itching and a tired feeling on using them, or form exposure to a bright light.
CAUSES.- The most frequent cause is prolonged effort of the accommodation in those who have some uncorrected error of refraction, exposure to severe cold or heat, or from foreign bodies. Often seen in those living or working in a vitiated atmosphere. It is also frequently associated with nasal catarrh, hay fever, etc.
COURSE.- It may be either acute or chronic, and when chronic it may cause a blepharitis, or become a catarrhal conjunctivitis.
TREATMENT.- See conjunctivitis catarrhalis.
Conjunctivitis Catarrhalis is a hyperaemia of the conjunctiva plus a discharge from the membrane-a simple hypersecretion. The healthy conjunctiva secretes mucus mixed with effete epithelial cells, and, when abundant, it becomes tenacious, stringy and with it small masses of pus. The difference between catarrhal and purulent ophthalmia is simply one of degree; in catarrh the secretion contains elements of pus, but still is never really purulent, and is much less likely to destroy the corneal epithelium by maceration than does the purulent.
SYMPTOMS.- These are the same as found in hyperaemia, but of a higher degree; the itching, smarting and burning sensations, the photophobia, lachrymation and redness of the eye are all present, and, from the greater inflammation and infiltration, we have chemosis. The discharge from the eye may be more or less excessive, but of a bland or muco-purulent character. The amount of secretion varies, and at night it is apt to accumulate and cause crusts on the cilia. The patient often complains of a temporary blurring of vision and black spots before the eyes, due to small flakes of secretion passing in front of the pupil.
COURSE.- An acute attack does not usually last more than from one to three weeks, although it may run into the chronic, form, especially in cachectic persons, or from unfavorable surroundings. In the chronic form the discharge is less contagious, and the disease is often associated with an inflammation of the lachrymal sac, especially if one eye only is affected.
CAUSES.- In the acute form, where there is a muco-purulent discharge, it is certainly contagious. It may appear as an extension of a nasal catarrh, from an affection of the eyelids, or from an inflammation of the lachrymal sac. Frequently occurs from an exposure to cold, from dust or smoke, from confinement in a close or vitiated atmosphere; often due to refractive errors, and is apt to occur with exanthemata.
DIAGNOSIS.- As other diseases of the eye may very closely resemble a catarrhal conjunctivitis, the differential diagnostic points should be considered. The principal diseases usually mistaken for conjunctivitis are iritis, episcleritis and keratitis.
DIFFERENTIAL DIAGNOSIS.
Conjunctivitis.
The redness of the conjunctiva general, and on pressure through the lower lid the injected vessels are seen to move with the membrane over the sclerotic. There is always redness of the fornix conjunctiva.
little and usually of the palpebral conjunctiva. There is a muco- purulent discharge, more, or less profuse The iris is clear a bright, the pupil reacts readily to light and the cornea is clear Episcleritis.
The redness is of inky-red color, conjunctival localized; it most often located over external rectus muscle,
Iritis. The redness is surrounds the accompanied by redness of the fornix or palpebral conjunctiva. The injected vessels are beneath the conjunctiva, and do not move with it. The iris is discolored, pupil reaction sluggish and in active and the vision is impaired.
Keratitis. The redness is deep-seated, and usually most marked around the cornea. The transparency of the cornea is always more or less diminish.
The photophobia is more intense and the lachrymation more profuse The vision may blurred and greatly impaired
TREATMENT.-The first point in the treatment should be the removal of any exciting cause. To accomplish this the lids should usually very first be everted and examined for the presence of a foreign body, severe pain in the which, if detected, should be removed.
If the conjunctivitis eye and head, depends upon any anomaly of refraction, this should be corrected., which is generally if due to straining of the eyes in reading, writing, etc. worse at night. (especially in the evening), or exposure to wind, dust or any bright light, as working over a fire, directions to abstain from over-use, or to protect the eyes from the injurious causes, should be given. Should the case be very severe, the patient may be confined to his room, though this is rarely required in pleasant weather. As a local remedy in acute inflammation of the conjunctiva, the use of ice is especially recommenced. It may be used in rubber bags made for that purpose or by wrapping it in a towel. If prescribed it should be used constantly for twenty-four or forty-eight hours or longer, according to the benefit derived. Cleanliness especially should be required. To prevent the formation of crusts on the lids, the edges may be smeared at night with a little vaseline, simple cerate, cream or the like.
In conjunctivitis, after the acute symptoms have subsided, we sometimes find the inflammation will come to a standstill, notwithstanding our most careful selection of remedies. In these cases a mild astringent will be found advisable, and the two following prescriptions have proven of much value :
Rx. Sodae biboratis,……………… Dj Aquae camphorate,…………….. z3iij.
Misce……………….
Rx Zinci sulph.,……………….gr. ij.
Sodii chlorid,……………….gr. iv.
Aquae dest.,………………. 3xi Misce.
Instill a few drops in the eye four times a day. Atropine should not be used unless there is iritic complication.
The attendants should be warned that the discharge is contagious, and that the sponges, towels, etc., used upon the patient should not be employed for any other purpose.
The administration of the internal remedy is, as a rule, all that is necessary in this disease. In the following list of remedies will be found those most frequently indicated. For special indications see Remedies in Conjunctivitis, page 214. Aconite, Pulsat., Euphras., Apis, Rhus, Sulphur, Arsen., Mercurius Sol., Hepar, Graphites, Belladonna, Sepia., Allium., cepa., Alumina., Argent., nit., Calcarea., Causticum, Chamomilla, Cinnabar., Ignat., Nux vomica, Sanguinaria, Zincum.
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.