TREATMENT.- Scraping the bottom of the ulcer with a sharp spoon and the local use of a 1/1000 solution of corrosive sublimate has proven of decided value in this form of ulceration. Ipecac, Conium and Hepar have been the most serviceable remedies in my hands.
Keratitis Neuro-Paralytica.- The cause of this fortunately rare disease is a paralysis of the ophthalmic division of the fifth nerve which results in a loss of sensibility of both the cornea and conjunctiva, thus allowing external irritants which, under normal conditions, are rapidly removed by winking, to remain in contact with the cornea and create a traumatic inflammation. It is further claimed by some that the paralysis also causes an interference with the trophic fibres which preside over the nutrition of the cornea. The cornea becomes dull and cloudy the epithelium of nearly the entire cornea is thrown off. The cloudiness of the cornea at its centre increases, breaks down into pus and a large ulcer with hypopyon is formed. The course of the disease off the disease is slow and characterized by absence of pain and slight symptoms of irritation. The paralysis of the nerve may result from injury, tumors, syphilis, etc.
The prognosis in all these cases is necessarily bad as dense opacities form over the entire cornea.
TREATMENT should be to protect the eye from external irritants hence, a compress bandage should be applied. The use of electricity to stimulate the nutrition of the nerve is of great value. Otherwise, the treatment should be that of ulcers in general. Sepia has given very excellent results in this disease. (Shepard).
Keratitis Bullosa.- This is characterized by an elevation of the epithelium, and according to Landesberg, Archiv. Ophthal and Otol., vol. vi., p. 135, 1877. of some of the corneal layers as well, from an effusion of slightly cloudy fluid. The elevation is of considerable size and of a sacciform appearance. Its approach is accompanied by a severe attack of periorbital neuralgia, photophobia and acute congestion of the eye. After a few days rupture of the bullae takes place and a more or less deep ulceration remains, which finally heals as described under ulcers. The pain in this affection is usually very severe, paroxysmal in character and ceases after the breaking of the covering. The disease usually follows upon other diseases of the eye, such as glaucoma and irido-cyclitis. There seems to be a tendency to recurrence of these attacks and, from this fact, together with a case seen by Tangeman Archiv. Ophthal, vol. xvii, p. 92, 1888. in which there was distinct malarial history with a cure from large doses of quinine he suggests the possibility of its cause being malaria. Fick says: “The nature of the disease is not known, the best presumption is that some disease of the corneal nerves is at the bottom of it.”
TREATMENT.- To relieve the pain, remove the envelope of the bullae and then treat as an ordinary ulcer.
Abscessus Corneae.- By corneal abscess we mean a circumscribed collection of pus within the layers of the cornea.
PATHOLOGY AND COURSE.- There is at first an infiltration of round cells into the corneal tissue. The pressure from these cells upon the parenchyma of the corneal causes a mortification and fatty degeneration of the parts involved and thus a pus cavity is formed which is generally the shape of a flattened globe or ovoid. Trabeculae are sometimes found extending from one wall to the other. The cavity is filled with round cells and a fatty, cheesy detritus. The surrounding corneal tissue is also infiltrated. The abscess may heal at this stage without further destruction. If so, it begins by the formation of new blood- vessels, the cells and detritus become absorbed and the walls of the cavity heal together; or the cavity may be partially or totally filled with connective tissue and then the blood-vessels either atrophy and disappear or remain persistent. As a rule, however, the abscess does not heal at this stage but, instead, more cells immigrate and are at the same time formed within the cavity and thus more and more of the parenchyma is destroyed. This ulceration usually extends until the outer surface is reached and an ulcer is formed. More rarely the destructive process extends inward, through Descemet’s membrane, into the anterior chamber. Lastly the abscess frequently extends in both directions at the same time and results in perforation of the cornea, with an escape of the aqueous and hypopyon, and a prolapse of the iris takes place. The further progress of the disease from this point has been described under ulcers.
SYMPTOMS.- The beginning of this affection is in the deeper layers and usually at about the centre of the cornea. There appears a round, circumscribed gray opacity, in which may be seen short gray striae. The surface of the cornea over the abscess may be slightly raised at first but latter it becomes sunken in, simply depressed not ulcerated. Photophobia, lachrymation and ciliary neuralgia are, as a rule, very severe. There are usually violent symptoms of irritation, such as intense injection of the conjunctival and ciliary vessels, chemosis even is very apt to be present. The pupils are contracted, iritis is apt to be present and hypopyon is usually found. The disease as a rule is a most painful one; the terrible pains often radiate to the occiput and teeth, causing sleepless nights etc.; in fact, in some cases, the pain seems to equal that of acute glaucoma or cyclitis. The intense pain is evidently occasioned by implication of the uveal tract and coincides with the appearance of hypopyon. Very rarely we will meet cases of torpid abscess with but slight symptoms of irritation. Sometimes there are several superficial infiltrations close to each other, which may extend in circumference and depth, coalesce and give rise to a large abscess which may leave a dense opacity or lead to an extensive slough of the cornea. The disease usually shows a tendency to extend in depth rather than breadth. Relapses may occur and the affection thus becomes chronic in character.
CAUSES.- An abscess originates by infection, usually by some slight abrasion of the epithelium, as from the scratch of a fingernail from a branch or leaf striking the cornea, or from any foreign bodies flying into the eye. The pyogenic organisms that cause the suppurative process may arise from the substance that causes the abrasion, or may be present in the conjunctival sac, due to catarrh, trachoma or blenorrhoea of the lachrymal sac. This form of abscess occurs almost exclusively in adults of the laboring class. The infection may also occur through metastasis, from the germs circulating in the blood, as in smallpox typhus, scarlet fever, etc. Metastatic abscesses may be found in children as well as adults.
PROGNOSIS is as a rule, unfavorable as a permanent opacity, more or less extensive, always remains. Where there has been no perforation in convexity may appear normal; but after the escape of the aqueous, we may have any of the conditions following perforation as described under ulcers.
TREATMENT.- (See Ulcus Corneae, page 246.)
Descemetitis (Keratitis punctata, Keratitis Posterior).- An inflammation of the membrane of Descemet pure and simple is of rare occurrence. This disease is most frequently described as a punctate keratitis and the whole subject is so thoroughly mixed up with serous iritis in ophthalmological literature that a clear understanding of the two condition is somewhat difficult (see Choroiditis Serosa)
SYMPTOMS.- Pain photophobia, lachrymation ciliary injection dilatation of pupil and hypersecretion of aqueous humor are all of a low degree and may or may not be present. There is, however, on the posterior surface of the cornea more or less numerous small grayish or dirty white points, especially found over the pupil. These points may extend into the parenchyma and may result in a sclerosis of that tissue. Its course is always long-lasting and obstinate to treatment. It has great tendency to recur, and periodical aggravations are frequent.
CAUSES.- Women seem to be more subject to this affection than are men or children. It is often ascribed to some constitutional dyscrasia, such as syphilis, scrofula, etc. The condition described is very frequently associated with a serous inflammation of the iris or uveal tract, still I am convinced that it can occur primarily.
PROGNOSIS.- Entire recovery may take place and the cornea resume its normal characteristics, or the opaque spots may remain permanent, and especially so if the cornea proper has been involved.
DIAGNOSIS.- As this disease so closely resembles serous iritis, we will contrast the differential diagnostic points.
Descemetitis
May occur alone.Hypersecretion of aqueous with little if any cloudiness. Punctate spots on the posterior surface of the cornea, which are not triangular in shape, do not change position on movement of the head, but are permanent and more often at the centre of the cornea over the pupil. Anterior chamber normal. No discoloration of iris. Tension is not increased.
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.