Conjunctivitis Follicularis is very frequently found and presents a very similar appearance to that met in trachoma, and is often mistaken for it.
PATHOLOGY-It is a simple hypertrophy of the lymph follicles, which microscopically are found to have a delicate reticular connective tissue, in the meshes of which are found lymph corpuscles and free nuclei, and are also permeated by fine capillaries.
SYMPTOMS-The conjunctiva appears filled with small, round, pinkish prominences, occupying the cul-de-sacs especially of the lower lid, where they are first noticed and always more prominent. In advanced cases they are arranged in rows, running parallel with the margin of the lid, and later may involve the superior cul-se-sac and the angles of the tarsus. Occasionally they may be found on the tarsus, where they appear as small, whitish, slightly raised patches. (See Chromo-Lithograph, Plate 1, Fig.3.)
The condition comes on slowly and lasts for months or years. It is unaccompanied by any discharge except in the acute cases when it simulates a catarrhal conjunctivitis, and has but slight photophobia, with occasional painful sensations, but no marked symptoms.
CAUSES-Usually results from bad hygienic surroundings and is often endemic in schools, asylums and prisons. The use of atropine in some cases will cause it. This disease is often complicated by a catarrhal conjunctivitis when we have the symptoms of irritation, discharge, etc. The disease is mostly met with in children and appears to be contagious. Follicular conjunctivitis never leads to subsequent shrinking and cicatrization.
TREATMENT-Fresh air, change of climate and proper hygienic surroundings are a great aid to the cure of the trouble. Local applications, such as those used in trachoma, have not proved of much benefit, although mild astringents will in some cases be of help. Correct any errors of refraction that may be present. Pressing out the contents of the follicles between the thumb nails, or by Knapp’s roller forceps, as described under trachoma, will cure the disease in a much shorter time than under any other method of treatment. We have seen a number of cases of follicular conjunctivitis promptly and quickly cured by the use of Knapp’s forceps, with little or no reaction, and we believe this operation is the best treatment at present known for aggravated cases of follicular conjunctivitis promptly and quickly cured by the use of Knapp’s forceps, with little or no reaction, and we believe this operation is the best treatment at present known for aggravated cases of this disease. The use of electricity is also of much value; but, as each follicle has to be punctured with the needle, the treatment is necessarily very tedious.
The local use of corrosive sublimate as described under trachoma is of much service in this disease.
The internal administration of Natrum mur., Euphras., and Sepia has cured some of these cases. See Remedies in Conjunctivitis, page 214.
Conjunctivitis Trachomatosa.-(Granular Lids, Trachoma, Egyptian Ophthalmia) Is an infectious inflammation of the conjunctiva, that is characterized by its chronic course and hypertrophy of the conjunctiva with a purulent infectious secretion. This disease has received numerous sub-divisions and classifications, we prefer that of granular and papillary. The great majority of cases, however, are of the mixed variety and so distributed that the most prominent feature over the lids is the papillary proliferation, while the trachoma granules are more characteristic toward the cul-de-sacs.
PATHOLOGY-This has been the subject of much dispute and still does not seem to be definitely settled. Some claim it to be a circumscribed hyperplasia of the lymphatics normally found in the reticulated connective tissue of the conjunctiva, thus forming true lymphoid follicles; while others claim they are new growths. They consist of small rounded masses made up the lymphoid and connective tissue cells, surrounded by a fibrous capsule and traversed by blood-vessels and connective tissue fibres. Swanzy Diseases of the Eye, 1897, p. 112. says: “The trachoma bodies have no capsule as have the follicles but seem to grow from or in the stroma of the conjunctiva.” They are to be regarded as new growths in the conjunctiva. The granule may undergo fatty degeneration and its contents be pressed out, or the connective tissue of the granule may increase and, from ultimate contraction, result in entropium. De Wecker Ocular Therapeutics. says: “A granulation lives and dies feeding on the parent that gave it life-it consumes the conjunctiva.” Hence it is a malignant product, while follicles or purulent conjunctivitis are essentially benign.
SYMPTOMS-They appear as yellow or reddish-gray translucent, roundish elevations, looking like frog-spawn (Fig 58), and are generally found in the retro-tarsal folds and the angle of the lids in the earliest stages. When occurring in the conjunctiva over the tarsus they are smaller and less visible because the membrane is so closely adherent to the tarsus. In this situation they appear as small bright-yellowish points deeply imbedded in the membrane. As the disease advances they extend in the worse cases, over the ocular conjunctiva and even upon the cornea. They are oval in shape and broader and less prominent than the hypertrophied follicles. (See Chromo-Lithograph, Plate 1, Fig. 4). There is some drooping and swelling of the lids and a slight secretion of a purulent character, causing some agglutination of the lids in the morning. The irritation of the eye and the quantity of the discharge is much increased in fresh cases or in acute aggravations of old cases. Pain, photophobia and lachrymation may be present and, during acute aggravations, become very severe.
COURSE-The disease is usually very insidious in its course. As it progresses the granulations increase in size and become covered with fine capillaries, the conjunctiva becomes red and infiltrated and secretes a muco-purulent discharge, the papillae swell, increase in size and blend with the granules. We have then the conjunctiva appearing as a fleshy mass, in which we are no longer able to distinguish the individual granules or papillae. Then a retrograde process sets in, and terminates in a cicatricial state with contraction of the conjunctiva. The formation of cicatrices is shown first by narrow whitish striae in the red thickened conjunctiva. These striae unite to form a delicate network. These lines grow broader, the islands they enclose smaller until the whole conjunctiva becomes pale, thin and smooth. Sometimes the neoplasm appears polypoid excrescences or condylomatous masses.
CAUSES-Trachoma is the result of infection from the secretions of an infected eye by some direct transfer and is probably due to some micrococcus. In the majority of cases trachoma requires months or years to run its course. Trachoma may appear at all ages, except in the very young. It may be either acute or chronic, and we may have acute exacerbations of an existing chronic trachoma. It is usually met with in places where the population is over crowded, ill-fed and amid unfavorable hygienic surroundings. Negroes in this country seem to enjoy great immunity from trachoma True trachoma is very rarely seen among the better classes, but is often endemic in public institutions, asylums, etc.
COMPLICATIONS-The conjunctiva in long existing cases, undergoes fibroid degeneration, atrophies and appears as grayish white cicatricial bands, usually running parallel with the border of the lid. The most frequent sequelae of trachoma is the distortion of the lid due to the cicatricial contraction and resulting in trichiasis and entropium. Symblepharon may also result from the same cause. There may be also more or less dryness and shrivelling up of the conjunctiva, which sometimes goes on to complete destruction of the conjunctiva-xerosis. The roughened condition of the conjunctiva causes a superficial vascularity of the cornea, with a proliferation of the epithelial vascularity of the cornea, with a proliferation of the epithelial cells between the epithelium and Bowman’s membrane, resulting in an opacity of the cornea called pannus. Later the whole cornea may become softened, lose its resistance, yield to the intra-ocular pressure and bulge. Occasionally the granules extend and may even be found in the cornea. Ulcers and abscesses of the cornea or a catarrhal or purulent conjunctivitis are very frequently found associated with trachoma.
PROGNOSIS- In the early stages, when under careful treatment, resolution may occur in a short time. Later, however, the disease is more stubborn, its duration almost unlimited and it leaves changes in the lid or cornea which may produce more or less serious disturbance of vision and even blindness
DIFFERENTIAL DIAGNOSIS.
—————————————————————– Conjunctivitis Trachomatosa. affects especially the upper lid- particularly the retro-tarsal fold. The granule is oval, reddish-gray and more or less opaque; it is imbedded in the membrane, and is less prominent than the follicle and it may be found on the ocular conjunctiva a even the cornea. In the granular variety, the affection, as a rule, soon takes on the mixed form, characterized by the presence of follicular and papillary hypertrophy in addition to the neoplasma There is also general lymph infiltration of the conjuntiva and of the deeper tissues the lid, including the tarsus, great proliferation of the epithelium and the formation of new vessels. Frequently accompanied by pannus. Very seldom met with in children.
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.