Subjectively the patient will usually complain of more or less intense photophobia, lachrymation and ciliary neuralgia, all due to an exposure of the terminal filaments of the corneal nerves from loss of substance, and from this we will sometimes find a slight superficial ulceration, creating more disturbance than will sometimes be present in a deeper and far more serious ulcer. Occasionally there will be met cases of slight superficial ulceration, hardly more than abrasions of the epithelium, with but very little redness, yet the most intense photophobia (so much that the child will lay all day with the head buried from the light) which will last for months without in the least yielding to treatment.
COURSE.-In majority of cases the course of an ulcer is acute and rapid, but in others it may be chronic and protracted, obstinately defying all treatment until perhaps perforation has taken place, when it will at once begin to heal. In favorable cases only the portion of the cornea involved in the primary infiltration breaks down, when the ulcer cleanses itself and rapidly heals. Very often, however, the infiltration extends, involving the healthy cornea either in depth or breadth, breaks down into pus and the ulceration increases in size or depth. In the former case large opacities result, while in the latter perforation threatens. The extension of the ulcer may take place in one direction while repair is going on at the other end (serpiginous).
CAUSES.-Corneal ulcers frequently occur from some form of conjunctivitis and are apt to vary in degree, according to the severity of the conjunctival disease, from a superficial abrasion to a slough of the entire cornea. Injuries frequently lead to ulcerations of the cornea in various ways. A foreign body removed by inflammation and suppuration leaves an ulcer. Wounds or operations may result in ulcerations when the healing by first intention is prevented by impurities, by re-opening, or by bad adaptation of the wound. Chemical agents may produce a slough. Friction of the cornea, from inverted eyelashes, from calcareous concretions or foreign bodies in the tarsal conjunctiva or colds may cause either an ulcer or an abscess. Paralysis of the orbicularis palpebrarum, ectropium, exophthalmic goitre, etc., cause ulcerations from exposure of the cornea to external irritants. Deficient nutrition in children, and the exanthematous diseases are very common causes. Corneal ulceration is frequently found in the working classes, due to neglect of some conjunctival catarrh and their greater liability which at the same time carries infectious matter into the wound.
PROGNOSIS.-Favorable as a rule, but depends upon the condition of the ulcer, and upon the age and general condition of the patient. When situated near the centre of the cornea the vision is much interfered with, and when more peripheral the vision is but slightly, if at all affected. Ulcers that have advanced as far as the substantia propria always leave an opacity. Superficial ulcerations are far more favorable as to the resulting opacities than are deep ones. Ulcers that heal with vascularization of the cornea leave opacities. In children and youth there is always a more complete regeneration than in advanced age. Very deep ulcerations from ophthalmia neonatorum may heal with only a slight opacity. In old or debilitated persons there is often a more extensive opacity than would be expected from appearance. Irritants, such as dust, smoke, etc., increase the density of an opacity. In cases of central ulceration, always advise the patient at the first examination that there will be more or less loss of vision.
RESULTS.-If an ulceration extends and causes a perforation of the cornea, a long train of results may follow. When the perforation occurs, the aqueous flows off and the iris and lens come forward into apposition with cornea. If the perforation is small, as the anterior chambers refills, the iris may be forced backward into place and the cornea heal with no synechia, but, in larger perforations, the iris falls into its margins, or bulges through, and the cornea healing, it is held there as a synechia called leucoma adherens, or prolapsed iris; the latter, exposed to external irritants, may become purulently inflamed and be the starting point of a purulent irido-choroiditis. If the entire cornea is destroyed there is a total adhesion of the iris to the cornea (leucoma adherens) and the new cicatricial tissue may not withstand the intra-ocular pressure, and staphyloma, either partial or total results. Instead of staphyloma resulting from the cicatricial tissue, it may flatten and atrophy of the globe follow. If the rupture of the cornea is extensive and sudden from a fit of coughing, sneezing, etc., there may occur a dislocation of the lens or even its entire escape from the eye, a prolapse of the vitreous, or an intra-ocular haemorrhage. Occasionally a perforation will not heal, leaving a fistula of the cornea. An anterior capsular cataract may result from a small central perforation.
TREATMENT.-Our chief reliance must be placed upon the carefully selected homoeopathic remedy, as by the use of our remedies we can greatly cut short the course of the disease. Superficial ulcerations of the cornea will not usually require local treatment, unless caused by granular lids (see Conjunctivitis Trachomatosa, page 204), or by entropium, inverted lashes, etc., in which case the cause must, of course, be first removed. Severe cases, not dependent upon granular lids or traumatic causes, will be greatly improved by the use of a bandage. Atropine may be of service in rare cases, with much photophobia and deep ciliary injection, though it is not commonly necessary under appropriate homoeopathic treatment. If the palpebral aperture is much shortened and the eyelids thus press upon the eyeball, the outer canthus may be divided (canthoplasty) so as to relieve the increase pressured on the cornea.
In the treatment of ulcers and abscesses of the cornea, local and dietetic measures are of great importance. If the ulcer is extensive, the patient should be directed to remain quiet in the house (in bed, if possible), that absolute rest may be obtained. As this disease is more often found in weak, debilitated subjects a very nutritious diet should be prescribed, and it may even be necessary to use stimulants; in these cases, the concentrated tincture of avena sativa, ten-drop doses four times a day, or the use of cod liver oil, will be found of great service.
As a rule, cold applications are injurious, except occasionally in the first or inflammatory stage of superficial keratitis or in ulcerations of the cornea occurring during the course of pannus. Hot poultices also are not advised, except in indolent ulcers which are deep, non-vascular and have no tendency to heal, in which they may often be employed with advantage.
Bandaging, upon the other hand, is of the utmost importance in the treatment, even in some cases, producing a cure alone. In all cases in which the ulcer or abscess is deep, or obstinate to treatment, a protective bandage should be immediately applied. It is usually sufficient to bandage only the affected eye (if one be healthy), unless the ulcer be very deep and extensive, when both eyes should be covered. The objects of the bandage are, to keep the eye quiet and protected by its natural coverings, the lids, from all irritating causes, such as wind, dust, etc., and to keep the eye warm, in order to promote local nutrition. The bandage is also of much value when the ulcer is deep and shows a tendency to perforate; it then serves to support the thinned portion of the cornea against the intra-ocular pressure.
Atropine is not usually required in ulcers or abscesses of the cornea, unless the ulcer is central and has a tendency to perforate, or if iritis complicates the corneal trouble; then Atropine should be employed until full dilatation of the pupil is produced, which should be maintained. It may also be of service in relieving the great irritability and intense photophobia observed in some obstinate forms of corneal inflammation.
Eserine should be instilled if the ulcer tends toward perforation at the periphery, or if the intra-ocular tension becomes increased.
Aqua chlori used locally has proved beneficial in some cases, especially in the crescentic form and when the discharge of pus has been profuse. It may be used pure, or diluted one- half, one-third or even more. The peroxide of hydrogen and pyoktanin may also prove of much service in cases where the ulcer is accompanied by a considerable purulent discharge.
The use of the galvano-cautery, as described under hypopyon keratitis, has proven most valuable in many severe cases.
In those cases in which the ulcer is deep, with a great tendency to perforate, Saemisch’s incision is recommended. It consists in cutting through the base of the ulcer into the anterior chamber with a Graefe cataract knife, which is entered in the healthy tissue on one side and brought out in the healthy tissue on the other side of the ulceration, which is then divided by a sawing movement of the knife, after which Atropine is instilled and a compress bandage applied. The wound can be kept open by the aid of a spatula or Daviel’s spoon, for two or three days if desirable.
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.