Keratitis Pannosa is a vascular superficial inflammation of the cornea.
PATHOLOGY.-There is a formation of a neoplastic layer of cells beneath the epithelium and also in the corneal layers just beneath Bowman`s membrane. These cells develop into connective tissue, and blood-vessels, and capillaries form in them. There are two sets of these vessels-one a venous set continuous with the conjunctival vessels, and a deeper arterial layer arising form the conjunctival and sub-conjunctival vessels. Where the cornea is very red, opaque and of a fleshy appearance, it is called pannus crassum; if the blood-vessels are few and the cloudiness is slight, it is then called pannus tenuis.
This condition is sometimes classified according to its cause, pannus trachomatosus when due to trachoma, pannus eczematous when found in eczematous or phlyctenular ophthalmia, and pannus traumaticus when due to trichiasis, entropium, etc.
SYMPTOMS AND COURSE.-In the acute form of the disease we may find photophobia, lachrymation, ciliary neuralgia and both conjunctival and sub-conjunctival injection. When it becomes chronic, the irritability is but slight. The cornea becomes opaque, rough, uneven and filled with ridges. The disease usually extends from the periphery, where it is the thickest, to the centre, but it may be the reverse. Superficial and even deep ulcers may form in the pannus. The cornea may become bulged from a long-existing pannus causing a thinning and weakening of the cornea; or the reverse, flattening and atrophy of the cornea may ensue from sclerosis and contraction of the new tissue within the corneal layers.
CAUSES.-In a large majority of the cases it is due to trachoma, and is produced by the friction of the roughened conjunctiva on the cornea. From this cause the disease is usually confined to the upper half of the cornea, or affects that portion first. Pannus may also result from phlyctenular or purulent ophthalmia; from the friction and irritation due to inverted eyelashes, entropium or chalazion, or from exposure to external irritants, as in lagophthalmos.
PROGNOSIS.-If the case is recent and inconsiderable and the cause remediable, the prognosis is favorable; but in chronic cases the normal transparency of the cornea can never be restored and the ultimate effect upon the vision will depend upon the extent of the corneal invasion.
TREATMENT.-This should, of course, be mainly directed to the cause of the pannus, as elsewhere described. The general health should be promoted and the eyes may be protected from all intense light. In some of the indolent cases, where the pannus is dense and does not clear up after the relief of the cause, the use of warm fomentations applied for about one-half hour at a time, two or three times a day, together with massage with the yellow oxide ointment, may be of service. Atropine may be of service where the vascularity is excessive and should be used when there is a tendency to iritic complications. Eserine, however, seems to have a directly beneficial result as an aid to the healing process; but in using eserine the iris must be carefully watched for pupillary adhesions. The operation of syndectomy, in all cases due to trachoma where the cornea remains opaque and vascular after the granular lids have passed over into the cicatricial stage, may sometimes be very serviceable. The operation consists in dissecting away a narrow strip of the conjunctiva close to the corneal border for either a portion or the entire circumference of the cornea.
The administration of the homoeopathic remedy is, however, the most essential part of the treatment. Aconite, Aurum., Hepar., Mercurius sol., Rhus tox. and Sulphur are perhaps the ones most often of value. For special indications for the use of these and other drugs, see treatment of Ulcus Cornea, page 241.
Keratitis Vesiculosa (Herpes Cornea).-Small, roundish vesicles filled with serum appear upon the surface of the cornea and usually form in a line running across the cornea. They are due to a circumscribed upraising of the epithelium, in which a thin layer of the cement substance takes part. The disease appears in paroxysms, with very severe pain, which is only relieved upon the shedding of the vesicular envelope and the formation of a slight excoriation.
CAUSE.-The cause of this affection is probably some inflammatory change in the fifth nerve, as evidenced by its frequent association with ophthalmic herpes zoster, and also by the fact that the severe neuralgic pain usually precedes and often continues after the vesicles are healed. The disease is periodic, subject to relapses and leads to no serious lesion. It is accompanied by little or no inflammatory symptoms and the presence of the vesicle from its small size and transparency is often difficult to recognize.
DIAGNOSIS.- This disease may be mistaken for phlyctenular keratitis, but in this the elevations are clear, while in phlyctenules they are flatter and more greyish in color. In herpes there is no vascularization and the disease is rarely found under puberty. Phlyctenular keratitis is usually associated with more or less vascularity and is disease of childhood.
The treatment should be the application of warm fomentations, instillations of cocaine, electricity and the removal of the epithelial covering of the vesicle with forceps.
Ulcus Corneae.-The clinical sub-divisions of corneal ulcers are almost innumerable, it seeming from examination of the various text-books as though each author strove to find some new name for each differently located or shaped ulceration of the cornea. It has, therefore, been thought best to place the general study of all ulcers under one heading, with brief mention of one or two of the more distinctive varieties to follow.
PATHOLOGY.-The pathological changes in an ulceration of the cornea are, of course, the same in all cases (irrespective of any clinical sub-divisions), with the exception or variation as to the extent or amount of tissue involved, and hence the following description is applicable to all forms of corneal ulcerations: There is at first an infiltration of leucocytes into the cornea lamellae lying next to Bowman`s membrane. The number of these cells increase and Bowman`s layer, together with the epithelium, becomes raised and the latter begins to necrose. The destruction is first noticed in the epithelial layer, then the lamellae and Bowman`s membrane become destroyed and an ulcer is formed. The base of the ulcer is covered with pus, its walls are ragged and the adjoining tissue is filled with round cells. The epithelium surrounding the ulcer is thickened from proliferation cells. The lamellae, forming the base and walls of the ulcer, become bent toward the surface at an angle of about 45 degree. The ulcer from this stage may progress by the surrounding parts becoming more and more infiltrated and destroyed as described, or it may proceed to reparation, in which case the bottom of the ulcer cleanses itself, its margins lose their ragged appearance and vessels extend to the ulcer from the limbus. This is followed by a marked and rapid proliferation of the epithelium extending from the sides over the walls and base of the ulcer, while at the same time a new and delicate connective tissue formation is taking place upon the base of the ulcer beneath the epithelium and gradually pushing it forward until it has completely filled up the ulceration, so that the new epithelial layer becomes continuous with that of the healthy cornea. The new epithelial cells are mostly round, though sometimes cylindrical or spindle- shaped. This new formed tissue later becomes more dense and tough and assumes somewhat of a lamellar arrangement, but the lamellae are smaller, more irregular and intersect at obtuse angles. This new tissue is translucent, and although it may clear up somewhat, it never becomes perfectly transparent. If the ulceration extends, growing deeper and deeper, there is first a protrusion of Descemet`s membrane (keratocele), due to the loss of substance, causing a diminished resistance to the intra-ocular pressure, and later a perforation of the cornea with a prolapse of the iris into the corneal wound, where it may become attached.
SYMPTOMS.-The first objective symptom noticed is that the patient usually enters the room with the eyes wholly or partially closed from the dread of light, and, upon attempting to examine the eye, as we raise the lid the eye rolls upward in order to hide from the light and a flow of tears will result as the light strikes the eye. As a reverse to this, which may be called the usual occurrence, we may sometimes find cases with the eyes widely open and without 8the slightest photophobia. On opening the eye we are attracted to the redness of the eye, which is due to the injection of both the conjunctival and sub-conjunctival vessels and which varies greatly in degree. Then, upon examination of the cornea, we find at some point a loss of corneal substance, that is, instead of seeing the normal, smooth, glistening epithelial layer, we notice a depression which is opaque, saturated with pus and has ragged edges. The depression is usually irregular, thought of a general circular shape. The corneal tissue is also opaque for a varying extent around the ulcer from purulent infiltration of its lamellae. Sometimes one or more blood-vessels may be seen running to the ulcer from the corneal margin. There may also be present a collection of pus in the anterior chamber (hypopyon) or a burrowing of pus in the substance of the cornea (onyx) (Fig 63) or a bulging of Descemet`s membrane in the base of the ulcer (keratocele).
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.