SYMPTOMS.-Subjectively ciliary neuralgia is the most characteristic symptom, for in acute iritis the pain is always considerable;it is not confined wholly to the eye, but extends into the forehead and temples as well as frequently patients complain of shooting pains through the whole head. The pain of iritis is always worse at night and in damp weather. It is often increased by cold and relieved by warmth. There is usually but little sensitiveness to pressure, except when complicated by cyclitis. The amount of the pain as a rule indicates the severity of the inflammation, although Fick says lachrymation and photophobia are more trustworthy guides, increasing with the exacerbations of the inflammation and subsiding as the inflammation becomes less severe. In chronic or serous iritis there is sometimes almost complete absence of pain. Photophobia and lachrymation are usually well marked. Dimness of vision will often be complained of, and, when present, may be due to the exudation, cloudiness of the aqueous or to a congestion of the optic nerve or retina.
Objectively the lids may be red and puffy, and, on opening the eye, we will find marked ciliary injection, which should always direct one’s attention to iritis or some deeper inflammation of the eye. (See Chromo-Lithograph, Plate 1, Fig. 2.) The cornea will appear surrounded by a violet red ring of sub-conjunctival vessels; together with this there is an engorgement of the conjunctival vessels which in some cases amounts to a chemosis.
In the ciliary or sub-conjunctival injection there are numerous very fine, deep vessels extending from the corneal margin in an almost straight course directly backward and giving the appearance often described as a rosy zone; while in the conjunctival injection the vessels are far less numerous, more superficial, larger and more tortuous in their course. The breadth and intensity of the pericorneal injection is, like the amount of pain, a good indication as to the severity of the iritis. Discoloration of the iris is always present and is due to the addition of the reddish-yellow color, resulting from the congestion and infiltration, to the normal color of the iris; a blue or gray iris changing to a green and a black or brown iris to a reddish-brown color. The iris loses its lustre, assuming a dull, heavy look, instead of its normal, glossy, shining appearance. The pupil is sluggish and contracted. Posterior synechiae are usually present and are recognized by irregularities of the pupil seen when attempting dilatation with a mydriatic. (Fig. 66). The pupil may be partially or completely closed by the exudation, in this way forming exclusion of occlusion of the pupil. These adhesions of posterior synechiae form one of the chief and most serious complications of iritis. They interfere with the mobility of the pupil and render subsequent attacks more liable, with greater probability of further adhesions. The haziness of the aqueous is due to the cellular elements thrown off from the iris and suspended in the anterior chamber and may vary from a fine opacity to a hypopyon. A slight increase in intra-ocular tension is sometimes detected. Hyperaemia of the optic nerve is said to be almost invariably present in iritis, but owing to the opacities it can seldom be recognized.
COURSE.-Iritis may be either acute or chronic in its course. In the acute variety they run their course in about two to six weeks.
The chronic form of iritis lasts much longer and is apt to be overlooked, as the inflammatory symptoms and pain are very slight and in some cases almost entirely absent. In this form, frequently, the only indications of iritis will be very slight pericorneal redness, lachrymation, dimness of vision and posterior synechia. Recurrent attacks of iritis are very frequent, especially in the syphilitic, and the rheumatic form where other rheumatic affections exist. The tendency to recurrence is greatly increased by the presence of old adhesions.
CAUSES.-Iritis is rather rare in childhood, being usually found in adults from the 20th to the 45th year. It may occur in one or both eyes and seems to be found more frequently in men than in women. Scrofula and syphilis are most frequent causes (60 to 75 per cent. of the cases of iritis being due to syphilis alone, according to some authorities). Rheumatism and gout may cause iritis. It may occur after injuries, such as cataract operations, foreign bodies penetrating into the anterior chamber, etc. It may be secondary to other diseases of the eye, especially from the cornea and conjunctiva. Iritis frequently follows after severe constitutional diseases, such as variola, typhoid fever, etc., and and is not infrequently seen as a sympathetic affection. It is said to come on from colds and from over-use of the eyes.
PROGNOSIS.-This depends upon the stage of the disease and the treatment followed. If iritis is seen early, before adhesions have formed, it should be conducted to a perfect resolution;if, however, posterior synechiae are present, there will be more or less interference with vision, depending upon the size and strength of the adhesions. Relapses are very apt to occur in iritis, and are rendered more liable when posterior synechiae remain, owing to the constant traction upon the iris from the adhesions during papillary movements.
COMPLICATIONS.-Corneal affections may result from an iritis, but more frequently affection of the iris follows that of the cornea and is usually due to direct continuity of tissue through the ligamentum pectinatum. More important, however, are the secondary affections of the ciliary body and choroid. This complication would be suspected, if impairment of the vision increased; if the eye became extremely sensitive to touch, or if there was increased episcleral redness and most characteristic of all would be opacities of the vitreous, as revealed by ophthalmoscopic examination. The tension should also be watched in suspected involvement of the uveal tract, as in irido- choroiditis it is apt to be increased, while in irido-cyclitis it is the reverse. Glaucoma is liable to occur, especially where there has been total posterior synechiae, and is due to the accumulation of fluid in the vitreous chamber, resulting from the closure of the passage between the anterior and posterior chambers of the eye. Cataract, especially capsular, results from the adhesions of the iris to the the lens capsule.
DIAGNOSIS.-As iritis often resembles very closely an attack of acute glaucoma, the importance of an early diagnosis between the two diseases cannot be over-estimated, because the treatment of the two diseases in certain very essential respects is diametrically opposite. In iritis dilatation of the pupil is of the utmost importance, in glaucoma contraction of the pupil is equally essential. The differential diagnosis is, as a rule, readily made, but in rare cases it is almost impossible.
DIFFERENTIAL DIAGNOSIS.
Acute Glaucoma.
I. Usually a history of premature recession of the near point; that is the patient has been unable to use his ordinary glasses, but has been changing them every little while for stronger ones.
2. May have had periodic dimness of vision.
3. May have noticed a rainbow of colors encircling at light.
4. Onset apt to occur suddenly during the night, and sets in with severe pain in the eye and head which increases in severity and is often accompanied by vomiting, fever, and general prostration. Attacks usually brought on by some sudden excitement or grief.
5. Causes. Especially a disease of old age, very rarely found under the of thirty-five, usually in one eye. Often hereditary, sex no influence, most frequently in hypermetropic eyes. May be due to neuralgia of fifth nerve, irritation from decayed teeth. Hysteria, convulsions, nervous excitement, anxiety, mental disturbances, anger, fear, etc., are predisposing causes also gout, acute rheumatism, atheroma, climatic changes, intoxication, indigestion fever, sleeplessness, etc. Atropine will also cause it in some eyes.
6. Lids may be swollen and oedematous.
7. Conjunctiva inflamed, chemosed.
8. Sub-conjunctival or scleral injection.
9. Lachrymation and photophobia.
10. Cornea hazy, may have lost its sensitiveness to touch.
11. Iris may be discolored.
12. Pupil sluggish and dilated.
13. No synechiae or exudation in pupil.
14. Greenish reflex from pupil.
15. Aqueous cloudy, anterior chamber shallow.
16. Intense pain in the eye and head.
17. Eyeball is hard.
18. Eye sensitive to touch.
19. Vision impaired and field contracted.
20. Ophthalmoscopic examination often difficult from haziness and general inflammation, but if possible find excavation of optic disc, retinal arteries small and pulsate, retinal veins enlarged.
Iritis. 1. Usually no such symptom.
2. Usually no such symptom.
3. Usually no such symptom.
4. Onset more gradual, with much less severe pain, and no constitutional symptoms.
5. Usually in adults from the twentieth to the forty-fifth year.
May occur in one or both eyes, more often in men than women.
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.