Always leaves a cicatricous membrane.
Papillary Trachoma Its location is predominantly over the surface of the tarsus instead of its borders. The enlarged papillae are of a bright red or bluish-red color, which gives the lid a velvet injected appearance. Is more rapid in its onset. Papillary Trachoma, as described by some, is a hyperaemia, inflammation and hypertrophy of the normal papillae of the conjunctiva. Their elevations are mostly found on the surface of the conjunctiva over the tarsus, which gives to it a velvety appearance, and is always most pronounced upon the upper lid. There is also a proliferation of the epithelium. This gives the conjunctiva at first a red, roughened appearance, and later that of a swollen, bright red mass, studded with elevations. If uncomplicated, the inflammatory product may be absorbed and the conjunctiva restored to its normal condition.
Conjunctivitis Follicularis.
Affects especially the lower lid, particularly the cul-de sacs. The follicle is round or elongated, pale and semitransparent: it is more prominent and sharply raised above the surface of the conjunctiva. Never causes pannus. Found especially in children. Entirely recovers; leaves no cicatrical membrane.
TREATMENT-As these forms of conjunctivitis are usually found among the lower classes or those who are constantly exposed to wind and dust, care should be taken that these exciting causes be removed as far as possible; cleanliness and proper hygienic measures are very important aids in the treatment of this affection. It should be remembered that the discharges from granular lids are contagious, and that whole families or a whole school may be inoculated from one member by an indiscriminate use of towels etc.; therefore, strict attention should be paid to the prevention of its extension. All trachoma patients should have their own washing materials, linen, bed, etc., and in schools, institutions, etc., the cases should be isolated from the other inmates.
It a cure can be effected by internal medication it seems to be more permanent than if total reliance is placed upon local applications, but I do not hesitate to use local remedies if there is no particular indication for any special drug, or if the case proves very obstinate. In acute trachoma or acute aggravations of chronic granular lids, ice compresses will prove very agreeable to the patient and aid materially in controlling the intensity of the inflammatory process. In chronic granular inflammation of the conjunctiva, especially when complicated with pannus, which is usually present, local treatment will be found of the greatest service. The following topical applications have been followed by more favorable results in my hands than any others.
R/ Acidi Carbolici………………………….gtt vi
Glycerini…………………………………..zj
Misce
Acidi Tannici…………………………….gr.xv
Glycerini,…………………………………zj
Misce
They should be applied with a camel’s hair brush to the everted lids once a day. Other applications which have also proved beneficial in individual cases are alum, used as a powder, in a saturated solutions with glycerine and in the crude stick; cuprum aluminatum and sulphuricum used in crystals; nitrate of silver in a weak solution (gr.ij-x ad z), and bichromate of potash in a saturated solution.
The local use of corrosive sublimate in solutions of varying strengths, from 1 to 1000 to 1 to 200, gives extremely satisfactory results in many cases. It may be used by simply rubbing the lids energetically with a hard wad of absorbent cotton moistened in the solution, or by making slight scarifications with the Johnson grattage-knife (Fig.59) and then applying the solutions. Under the use of cocaine there is but little if any pain, and but slight inflammatory reaction occurs except possibly from the stronger solutions. The scrubbing of the lids with the bi–chloride solutions should be followed up two or three times a week, and if followed up yields the best results of any treatment we know of. A number of operative measures have been suggested from time to time which have been credited with more or less success by different authorities. We shall, however, refer to but one operation in detail which, in our experience, seems to be the, most satisfactory, and that is the following, which may be called the operation of expression of the morbid substance with a roller-forceps, and is described by Knapp. Archiv. Ophthal, vol xxi. I, 1892. He uses the roller- forceps (Fig.60) made by having two steel cylinders so inserted into the forked end of a small but strong pair of forceps that they roll upon each other.
As the operation is rather long and more or less painful, a general anaesthesia should be employed. The lower lid is everted and may be superficially scarified with the Johnson knife, although scarification is by no means indispensable. One roller of the forceps is then pushed deeply into the fornix, and the other applied to the anterior portion of the everted lid, the forceps are then compressed and drawn forward, so that the tissue between the cylinders is milked out. The instrument is reinserted and the neighboring portion treated in the same way. This manipulation is repeated until the cylinders roll easily and evenly over the evacuated conjunctiva. The upper lid is then treated in the same way. Top reach the superior cul-de-sac, the tarsus may be drawn away from the eye with fixation forceps. special care should be taken to reach all parts of the conjunctiva at the fornix and commissures. The forceps should be frequently dipped into an antiseptic fluid in order to be kept clean and free from coagulated blood, which prevents the rollers from turning. Both lids of both eyes may be treated at the one operation, and but one operation is usually required. But slight reaction usually occurs, and the patient is not necessarily, though preferably, kept confined. The application of the corrosive sublimate solution, 1 to 1,000, or weaker, may be used immediately after the operation, if desired.
This method is of the greatest value in follicular conjunctivitis and in the cases of densely packed spawn-like granulations. When thoroughly done the conjunctiva is left perfectly smooth and assumes its normal appearance in from one to two months.
Excision of the retro-tarsal fold, as advised by Jacobson, has been extensively practiced. Treitel Therap. Monatshefte., 1889, 2 and 3. reported its trial in 170 cases with satisfactory results. It has at the same time been praised and condemned by many other authorities. From our own observation it has not given as favorable results by far as the operation detailed above.
The once much-lauded, Jequirity treatment seems now to be a thing of the past.
At the same time local treatment is employed, the carefully selected internal remedy (see page 214 ) should be administered.
The selection will usually be from the following list: Acon, Aurum., Mercurius, Rhus tox., Pulsat., Sulphur, Nux vomica, Argent. nit., Kali bich., Alumen, Alumina, Arsen., Belladonna, Calcarea Carb., Chininum mur., Cuprum, Euphras., Natrum mur., Thuja.
Conjunctivitis Phlyctenularis.-(Pustular, Scrofulous, strumous and Herpetic Conjunctivitis)
PATHOLOGY-Consists of a collection of lymphoid cells just beneath the epithelium raising it up. The apex breaks down, leaving a minute ulcer.
SYMPTOMS AND COURSE-In the most simple form we find on the ocular conjunctiva a slight triangular-shaped injection, at the apex of which there is a small reddish eminence. There is generally several of these, which may become absorbed, leaving no trace behind them; but usually the epithelial covering breaks down, forming an ulcer at the apex of the cone, which gradually inks to the level of the conjunctiva and then quickly heals. The smaller the nodules the greater the number as a rule, and the small ones disappear by absorption. Again we may find a very pronounced redness with the formation of a very large phlyctenule at the border of the cornea itself. (Fig.61). There may be several of these at a time or they may form successively. They break down and form large ulcerations that may be some weeks in healing, or they may perforate and cause staphyloma. Some times this form may be accompanied by a yellowish infiltration or abscess of the cornea. Finally, very large phlyctnules may form on the ocular conjunctiva; the inflammation extends, grows deeper and involves the sclera. They often ulcerate but usually only affect the superficial layers of the sclerotic and are of long duration.
There are sometimes no subjective symptoms, but usually excessive lachrymation, violent pain, intense photophobia and blepharospasm. Frequently, the child will liex with the eyes closed and the face buried in the pillow all day long. There is always a great tendency to relapses.
The disease will usually run its course in from eight to fourteen days, but, as relapses or successive crops are particularly liable to occur, the eye may not be entirely free from the trouble at any time for months or even years. The parents should always be warned that the child is liable to have recurrent attacks for years, often continuing until and ceasing with puberty. The prognosis is always favorable so far as the cure of individual attacks, the only danger being that subsequent attacks may involve the cornea and, leaving a macula over the pupil, affect in this way the vision.
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.