Anatomy.-The sclerotic is a dense, tough, fibrous structure, continuous with the cornea, and, by its strength, serves to maintain the form of the eyeball.
Its structure is similar to that of the cornea, excepting that it possesses blood-vessels and its fibres are coarser and less uniformly arranged. It also contains lymph channels, fixed and wandering cells, together with some pigment cells. The thickest portion of the sclera is at the posterior pole and the thinnest just behind the insertion of the muscles. In front it is covered by a loose episcleral connective tissue, and over that by the conjunctiva. Posteriorly, about 2.5 mm. to the inner side of the antero-posterior axis of the globe, it is perforated by the optic nerve, whose sheath joins with the sclera. The place of entrance constitutes a sieve-like perforation called the lamina cribrosa. Surrounding the optic nerve the sclera is perforated by blood-vessels and nerves known as the posterior or short ciliary, which go to the choroid, ciliary body and iris, and in front it is pierced by the anterior ciliary vessels. Near the equator four apertures transmit the venae vorticosae from the choroid.
Episcleritis.-Inflammation of the episcleral tissue may occur alone or with scleritis. It appears as a circumscribed swelling near the edge of the cornea and close to the insertions of the muscles. The bulging is of a dusky red or a dull purple hue. The most frequent situation of episcleritis is over the external rectus muscle, although it may occur at the inner side or either above or below. It may be accompanied by both conjunctival and sub-conjunctival injection, which is apt to be localized. There is usually photophobia, lachrymation and ciliary neuralgia, with some dull heavy pains around the eye.
Episcleritis frequently resembles very closely in a large phlyctenule of the conjunctiva; but overlaying the swelling of episcleritis are seen the conjunctival vessels, which are movable on pressure, while in a phlyctenule the conjunctival vessels do not run over the nodule. Episcleritis has a larger base, its color is darker and shows no tendency to ulceration. The course of an episcleritis is long, usually lasting for weeks and is apt to recur again and again. There is never any ulceration in this disease, as they always disappear by resorption. It is most frequently found in adult females, and has often been found in those of a rheumatic diathesis, and, De Wecker Ocular Therapeutics. says, “especially in the articular form, affecting the knees.” A slight cloudiness of the cornea near the elevation of the sclera is sometimes seen. The prognosis is unfavorable as to the duration of the diseases, but favorable as to the final outcome of vision.
The treatment of episcleritis and scleritis are practically the same and will be detailed after a few words upon the latter disease.
Scleritis (Sclerotitis).-Is an inflammation of the deeper layers of the sclera and is distinguished from an inflammation of the more superficial layers, episcleritis by its tendency to extend to other parts of the eye. This condition appears as a general faint pinkish tint, due to injection of the superficial vessels of the sclera. There may also be present a conjunctival injection, which is distinguished from that of the sclera by being a deeper red and movable over the pinkish hue of the sclera injection. As the inflammation increases the sclerotic assumes a deeper color- more of a bluish-red tint and sometimes covers the whole circum-corneal region. In the early stages of scleritis it resembles somewhat both iritis and conjunctivitis, and is differentiated from iritis by clearness of the aqueous and absence of adhesions, and from conjunctivitis by absence of secretion. There is apt to be quite severe pain in scleritis and it is undoubtedly of a rheumatic or gouty origin. Females are more subject to this disease than males, and disturbances of menstruation seem to be an exciting cause. Inflammation of the sclera is apt to lead, from ultimate thinning and weaking of its tissue, to staphyloma of the sclera which may be total involving the whole anterior part of the eye, or it may be partial confined to some one section.
As complications of this deep form of scleritis we may have a sclerotizing opacity of the cornea, an iritis or a choroiditis with opacities of the vitreous.
TREATMENT.-The local symptoms of this disease being usually few and indefinite, we are often obliged to derive our indications for remedies from the general symptoms of the patient.
If there is great ciliary injection and pain, a solution or Atropine may be employed, but it is rarely necessary.
Thuja.-This is a very valuable remedy in all forms of inflammation of the sclera, even if no characteristics symptoms are present. In most instances there has been great tenderness of the globe, intolerance of light and active inflammation, with a general cachectic condition, occurring in persons badly nourished, either scrofulous or syphilitic, and those for a long time deprived of fresh air.
Sepia.-Especially indicated in those cases dependent upon or associated with menstrual disturbances. The eyes feel fatigued when using them, a strained dragging sensation in the eyes. Everything gets black before the eyes during menstruation. Sepia cases are always aggravated morning and evening and in hot weather and relieved during the middle of the day.
Mercurius.-Inflammation of the sclerotic, which is thinned so that the choroid shines through. Steady aching pain in the eye all the time, but worse at night; also usually some pain around the eye, especially if the iris has become involved. Concomitant symptoms of flabby tongue, offensive breath, night pains, etc., are of great importance. The solubis and corrosivus have been most commonly employed, though the other preparations may be indicated.
Kalmia.-Sclero-choroiditis anterior. Sclera inflamed, vitreous filled with opacities, glimmering of light below one eye, especially on reading with the other, were indications present in one case in which Kalmia was of great service.
Aconite.-In the acute stage, if there is violent, aching, dragging, tearing, or burning pains in the eyeball with contracted pupil, photophobia and the characteristic reddish-blue circle around the cornea. The eye is usually quite sensitive to touch and feels hot and dry. Especially useful if caused from cold or exposure to dry cold air.
Aurum.-Low forms of scleritis in which the infiltration has extended into the parenchyma of the cornea. Moderate pain, redness and photophobia. Syphilitic dyscrasia.
Cinnabaris.-Inflammation of the sclera, with pain over the eye, usually aggravated at night.
Nux mosch.-Nodules over external recti, very large and painful. Patient very drowsy, with sleepy expression of eyes.
Silicea.-Sclerotic inflamed, with or without choroidal complication. The pains may be severe and extend from the eyes to the head and are relieved by warmth. Aching in the occiput corresponding to the eye affected.
Terebinth.-Inflammation of the superficial layers of the sclera, with a considerable redness and intense pain in the eye and corresponding, side of the head. Urine dark and scanty.
The following have also been used and are recommended: Pulsatilla, Spigelia, and Sulph. Staphyloma Sclerae.-Bulging of the sclera may be either partial or complete. When partial, it is usually at the ciliary region where the sclera is weakened, because perforated by the venae vorticosae and the anterior ciliary vessels; and between the insertion of the muscles, because of less resistence at these points. Staphyloma usually results from an irido-choroiditis, accompanied by an increase of the intra-ocular tension; or, it may result from simply thinning of the sclera from inflammation, sclerotico-choroiditis anterior, without increased tension.
If its course is very acute, we find conjunctival and sub-conjunctival injection, chemosis and intense ciliary neuralgia. The ciliary region is extremely sensitive to touch, the cornea and aqueous are hazy, the iris discolored and adhered to the lens, the vitreous is clouded with large shreds, tension increased, the vision and field of vision impaired. As the bulging increases it assumes a dusky, dirty-gray or bluish hue, due to the choroid shining through. The progress of the staphyloma is very slow and gradual. The curvature of the sclerotic will first be noticed to be slightly altered after an irido-choroiditis; the protrusion slowly increases, changing its white color for a bluish tint and will often assume a mulberry appearance, due to trabeculae forming a framework to the darker spots.
Inflammatory exacerbations come and go, each time increasing the staphyloma. When the bulging extends all around the sclera it is called annular staphyloma, and, when complete, may protrude so far as to be called buphthalmos. Total staphyloma can only develop in youth, for in adults the sclera becomes so rigid that it can only bulge in some weakened spot. Both partial and complete staphyloma may remain stationary, go on to atrophy from an inflammation, or, the bulging give way with escape of the contents of the eye, followed by subsequent inflammation and atrophy.
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.