SYMPTOMS AND COURSE.- In the inflammatory or active cases there is very severe pain and photophobia, with redness of the conjunctiva and some muco-purulent discharge. The ulcer may develop at either the margin or the centre of the cornea as a slight loss of substance usually oblong in shape, its base appears grayish, its edges raised and mottled or streaked with white. In the very early stage careful examination shows deposit upon the membrane of Descemet, giving the base of the ulcer an appearance as though coated with mud, and often a small quantity of pus may be seen in the bottom of the anterior chamber. The hypopyon increases as the ulcer spreads and gives the base of the ulcer a yellow color, as though due to suppurating corneal tissue. The rapidity of the ulceration is such that the entire cornea may be eaten away in two or three days. The ulcer always extends from its border, steadily and rapidly, either directly across, or around the entire cornea. In this way the nourishment of the cornea is cut off and slough of the entire cornea may ensue. Increase in the amount of the hypopyon is always an evidence that the destruction of the cornea is still going on. When a large perforation of the cornea is still going on. When a large perforation takes place, allowing of the escape of the hypopyon, repair may then set in. In the early stages of this disease there is usually excessive pain, but later on, owing to the cutting off of the corneal nerves by the ulceration, pain may be wholly absent. The disease may occasionally make its appearance in a far less acute attack, in which the inflammatory symptoms and pain may be so moderate that the subject will allow the condition to go on for several days before seeking advice, when we may find a considerable portion of the cornea affected, and the anterior chamber may be half full of pus. On watching these cases two processes may sometimes be seen going on at the same time, viz.: An extension of the destruction at one extremity of the ulceration and repair at the other end or seat of original infection.
Hypopyon.- The occurrence of pus in the anterior chamber may be accounted for in several ways, viz : by direct passage through the corneal canals, which communicate in the ligamentum pectinatum (through Fontana’s canals) with the contents of the anterior chamber; in cases where the abscess or ulcer is deep and near Descemet’s membrane it becomes affected together with the endothelial layer, the cells of which proliferate, become detached and fall into the anterior chamber; again, if the ulcer or abscess is situated near the cornea-scleral margin, the iris and ciliary body may become inflamed and through this inflammation hypopyon may form. Verdese Ann. di Ottalm., vol. xvii, I, p. 67 made a microscopic examination of an eye affected with hypopyon keratitis in its incipiency and found a small rupture of Descemet’s membrane. The ulcer had penetrated but one- third of the thickness of the cornea, but the layers beneath were infiltrated with leucocytes and otherwise unaltered; the iris was normal. From this he concludes that hypopyon is due to a bursting of Descemet’s membrane and the entrance of leucocytes from the ulcers.
CAUSES.- Being due to infection, it is most generally found in the poorer classes, where from want of care, decomposed matter is allowed to sojourn in the conjunctival sac. Leber Archiv. Ophthal., vol. xiv., I, 1885. attributes the cause to a fungus, which enters the cornea through some loss of the epithelium. This fungus he believes to be present in the air during the harvest season and secures lodgment in the secretions of a catarrhal inflammation of the conjunctiva or lachrymal sac. In the better classes the septic material is usually the outcome of an inflamed lachrymal sac, the secretion being retained and decomposed. Any abrasion from chips of stone or metal, or simple epiphora, by maceration of the epithelium, gives an opportunity for the infection. The disease nearly always occurs in adults over forty years of age.
TREATMENT.- For many years the treatment of this disease was the bete noire of all ophthalmic surgeons. Local and medical measures seemed to fail, iridectomy and paracentesis were tried without avail, when saemisch advised the slitting up of the ulcer, and to him is due the credit of suggesting the operation which is to-day most generally employed. Of late years the use of the actual cautery, or of either the galvano or thermo-cautery, has to some extent supplanted or been used together with the Saemisch operation. My own preference is for the galvano-cautery loop, and since its use I have seldom resorted to the knife. Gruening Von Graefe’s Archiv, xxv., pt. II, p. 285. advises using the point of a delicate platinum probe, brought to red heat in a spirit lamp, held behind the patient. The lids are separated and the eye steadied by the fingers of the left hand of the operator, while with the right hand the red hot point is applied to the arc or zone of propagation. The eye having been previously cocainized, the patient suffers no pain. Under the compress bandage the eschar is thrown off in twenty-four hours, leaving a clean ulcer which heals rapidly. He advises in the more advanced stages of the disease, where the floor of the ulcer is thin and infiltrated and the anterior chamber partly filled with septic material that the actual cautery be combined with Saemisch’s operation; the cautery destroying the septic material of the cornea. while the Saemisch incision removes the septic material from the anterior chamber. The operation of Saemisch and other treatment both local and medical, will be found under treatment Ulcus Corneae, page 246.
Ulcus Rodens.- The rodent ulcer unlike the ulcus serpens runs a very slow chronic course, often lasting for months, and affects only the superficial layers of the cornea. It appears as a small gray infiltration near the corneal margin which ulcerates, and when appearing to heal, relapses set in and more tissue is involved until it has extended over the entire cornea. It is accompanied by decided irritation, pain, photophobia, lachrymation and ciliary injection. The disease usually involves both eyes, occurs in debilitated people past middle life, and as it eats away the whole surface of the cornea results in complete loss of sight.
TREATMENT.- The cautery should be used to arrest the disease. Atropine and the bandage are of service to relieve the pain. For remedies, see Ulcus Corneae, page 248.
Asthenic Ulcer.- (Absorption Ulcer, Non-Inflammatory or clear Ulcer).- This form of ulceration differs, as its names imply, somewhat from those already described, and hence is briefly mentioned. It is but rarely seen, generally appears suddenly and most often in the central part of the cornea. The edges are jagged and outlines irregular, though more or less circular. The depth of the ulcer is often deceptive, owing to the bulging forward of its thin base (keratocele). This ulcer may remain stationary for weeks or months, then the edges may become vascular, the margins rounded off and the loss of substance be restored. Repair is often more or less incomplete and a slight facet may remain. It is usually found in adults and sometimes is seen symmetrically in both eyes and may go on to perforation. There is no infiltration either at the base or margins of the ulcer and no pericorneal injection. The only subjective symptoms is more or less interference with vision, according to its site.
TREATMENT.- Warm applications and a compress bandage may be applied and local irritants may be used to stimulate the ulcer. For remedies, see indications under Ulcus Cornea especially Conium, Kali bich. and Nux vomica
Marginal Ring Ulcer.- Is a deep, clear cut ulcer occurring at the corneal margin. There is but very slight infiltration and it may extend all around the cornea, causing a slough by cutting off the nutrition of the cornea. Healing may occur at one extremity while it is extending at the other. It is a very rare form of ulcer occurring usually in adults or old people whose nutrition has fallen very low, but may occur in children from a marginal phlyctenular infiltration.
Keratitis Dendritica (Malarial, Mycotic and Furrow Keratitis).- Under these various headings have been described a superficial ulceration of the cornea all of which have the one general appearance of narrow furrows with off shoots or ramifications which follow a crooked or zigzag course over the cornea (Fig.64). In these cases there maybe very intense photophobia, lachrymation and neuralgic pains in the eye, with but little inflammation or infiltration. It is generally considered to be due to some particular microbe and is apt to be rather chronic in its course. Emmert Hirschberg’s Centralblatt fur Augenheilkunde, October, 1885. found in two cases a peculiar bacillus in or on the epithelial cells. Kipp plus Trans. Amer. Ophthal. Soc., 1889, p. 331. describes the disease as malarial keratitis, and claims that, out of 120 cases that he had seen, all but about twelve were suffering from malarial poisoning.
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.