OPHTHALMIC DISEASES AND THERAPEUTICS BY A.B.NORTON.
Examination of the Eye.
The importance of a thorough and systematic examination, not only of the eye itself, but of co-existent general conditions, in order to determine the underlying states and to make a correct diagnosis, cannot be overestimated. Every patient should be examined systematically for both an accurate understanding of the case and for the preservation of careful records for subsequent use. The necessity of a thorough general examination varies with different cases. There is, of course, not the same necessity for an examination into the family and personal history, occupation, habits, condition of the various organs, such as heart, kidneys, nervous system, etc., etc., in cases of simple conjunctivitis as there is in the more grave ocular diseases. Furthermore, as the method of general examination or “taking the case” varies with different physicians, it will not be entered into here.
In the examination of the eye itself, we cannot emphasize too strongly the value of systematic methods. Many times has the ophthalmoscope revealed a retinitis or an optic neuritis in cases with a normal acuteness of vision, and no symptoms indicative of an intra-ocular disease. The records of a thorough examination to-day may be of the utmost value in the prognosis of some condition that may arise five, ten or twenty years later. Full records of each passing condition will often prove of great service in the treatment of subsequent similar conditions, and much of one`s success in diagnosis depends upon careful routine observation and record. Therefore, we would urge, the thorough examination and the full recording of all eye cases. The author`s method is in every instance to first determine the visual acuteness and any refractive error that may be present, the range and power of the accommodation, and the strength and balance of the extra-ocular muscles. The appearance of the lids, lachrymal sac, conjunctiva, sclera, cornea, iris, aqueous humor and lens are carefully noted; following this, a thorough ophthalmoscopic examination of the entire fundus should be made. The examination as to the field of vision and color-perception is not necessary except in more rare instances, and is therefore only made when the previous results indicate, the necessity. To avoid useless repetition, the method of determining the refraction and accommodation, the muscular balance, and the color-sense will all be detailed later on in the chapters devoted to these subjects.
Examination of the Outer Structures.-Much can often be learned before touching eyes for an examination of the individual structures by noting the general appearance of the patient and of the eyes. One important factor in children which is often neglected by many physicians is to first secure their aid and confidence. A few moments spent in acquiring the child`s trust and attention will give better results and save time later on. We can detect from a casual glance as the patient enters the room the presence or absence of photophobia, lachrymation and discharge from the eye-the character of the discharge, if purulent or mucus, thick or thin, bland or excoriating. A paralysis of the muscles can often be recognized by the inclination of the head, and the deviation of the eye will denote either a paralysis or strabismus. Twitchings of the lids, the face or other parts of the body will indicate nervous disorders. The expression of the face and the general physical condition are also to be noted.
The lids first attract our attention when we come to examine the eye proper. If swollen-whether hard and tense, or soft and oedematous-their mobility and position; their edges for distorted cilia, the presence of parasites or inflammation; their inner surface for granulations, cicatrices, secretions and foreign bodies.
To examine the inner surface of the upper lid and the superior cul-de-sac, which, as a rule, gives more characteristic indications than does the lower, and to remove foreign bodies it is frequently necessary to evert the upper lid. This procedure is quite simple after one acquires the knack or practice, but to the unaccustomed often difficult. The eyelashes of the upper lid are seized by the index finger and thumb of the left hand, the lid is then drawn downward and away from the ball, the point of the thumb of the right hand or a pencil is then placed above the tarsal cartilage of the lid and by a quick downward pressure of the thumb and a simultaneous upward movement of the left hand grasping the cilia the edge of the lid is turned over the point of the thumb. During the entire manoeuvre you must insist upon the patient`s keeping the eye downward, if not the eversion of the lid becomes unnecessarily difficult and painful. When everted the thumb of the right hand presses the edge of the lid backward against the eye-ball and holds it for examination.
The lachrymal puncta and sac should be examined for any obstruction, and by pressure over the sac notice whether any mucoid material or tears can be expressed from the puncta. The inspection of the conjunctiva shows us the presence of phlyctenules, pterygium, growths, adhesions, etc. The vascular condition of the eye affords most important information, and it should derive careful attention. Note if the redness is due to the large, tortuous, bright red superficial vessels of the conjunctiva, which are especially numerous toward the periphery and looser portion of the membrane, or if fine, radiating lines, pink in color, confined to the ciliary region and due to the episcleral vessels. The character of the congestion can be determined by gently rubbing the lower lid over the eyeball, when it will be seen that the coarser conjunctival vessels will glide over the deeper episcleral ones. In some cases we may note a leash of vessels, more or less pyramidal in shape, with the apex toward the cornea, indicative of an ulceration. Again, we may see a marked enlargements and tortuousity of the episcleral veins, pointing out a glaucoma.
The thorough examination of the conjunctiva and cornea in young children where there is much photophobia and inflammation is usually a matter of great difficulty. When, owing to these causes, there is a spasmodic contraction of the lids, their forcible separation can be best accomplished as shown in Figure I. The nurse or attendant seated at your side lays the child across her lap with the head held firmly between the surgeon`s knees. The attendant in this way can readily hold the child`s hands, feet and body while the head is held as within a vise by the surgeon`s knees. A towel should first be placed across the lap of the surgeon to prevent the staining of the clothes from any solutions that may be used. The surgeon then grasps the ciliary border of the upper lid with the index finger of the right hand and with the thumb of the left hand the border of the lower lid. In opening the eye the pressure must be mainly upward toward the supra-orbital ridge and just sufficiently backward to prevent the eversion of the lid. Great care must be used not to make too great pressure backward or downward upon the eyeball, because in an ulceration of the cornea (which is so apt to be present in cases where this method has to be resorted too) the pressure is liable to cause a rupture of the cornea with loss of the eye. Many an eye has undoubtedly been lost through careless and severe handling in an effort to examine the same. You will often have to hold the eye open for several minutes before a clear view of the cornea can be had, as it will roll so far upwards that the cornea cannot be seen until the muscles have become tired out and allow it to resume the direct position. In some cases, when one has become especially dexterous in this manipulation, they can open the lids by the use of the thumb and index finger of the same hand, leaving the other hand free to make any necessary applications.
As the examination of the cornea is greatly facilitated by the use of the oblique illumination, it should always be employed. This cannot be too strongly emphasized, as we have frequently seen our students by neglect of this method overlook some minute yet important diagnostic sign which was readily discernible by its employment. Make it, therefore, a routine practice in all cases when examining the anterior part of the eye. Its use aids the minute examination of the lids and conjunctiva, as well as the cornea, iris, lens and aqueous. By it we may often determine small superficial ulcers and abrasions, commencing interstitial infiltrations, faint opacities or nebulae, and particles of foreign substances imbedded in the cornea. The discovery of minute tears or abrasions of the corneal epithelium may be aided by the instillation of a drop of a two per cent. solution of the potassium or sodium salt of fluorescin. This should be dropped upon the cornea and followed by a washing with distilled water; any break of the epithelium will be made apparent by a deep greenish stain, which remains for about two hours.
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.