Part 36

_Treatment of External Ophthalmia, and its Consequences._—The exciting cause, if such exist and can be discovered, ought in the first place to be removed. The surface of the organ and of the palpebræ should be carefully examined, either with the naked eye or with a magnifying glass, in order to detect any small extraneous body which may be lodged in the part. In examining the inner surfaces of the palpebræ, it is necessary, to produce complete eversion, to bring the parts completely into view; and the most convenient method of accomplishing this is to lay hold of the ciliæ between the finger and thumb, and reflect the lid over a silver probe placed along its base. This can, by a little practice, be accomplished readily without using a probe, and even by the fingers of one hand only. This is the more necessary, as small particles of foreign matter lodge more frequently on the palpebral conjunctiva than on any other part. If a particle of glass, metal, stone, &c., be discovered, it should be gently removed by the flattened extremity of a silver probe, or by a scoop, a fine needle, or a delicate brush. In some cases washing the surface by means of a small syringe, filled with a bland fluid, is extremely useful; as when an impalpable powder has been thrown into the eye, and can with difficulty be removed, in consequence of spasmodic contraction of the eyelids preventing exposure of the parts. The application of an emollient poultice, with the addition of hyoscyamus, is beneficial when it has been found impossible to remove the whole of a fine powder. When particles of lunar caustic have, by accident, come in contact with the eye, they are to be removed, as soon after insertion as possible, by a fine hair pencil dipped in oil or fresh butter,—not in water. Small loose bodies are generally carried, by the increased lachrymal secretion, along the sulcus formed by the apposition of the eyelids, to the inner canthus, and there discharged. And, in order to favour this natural process for removing extraneous matter, the patient should be directed to keep the eyelids shut, and as quiet as possible, to cover them with his hands, and to blow his nose forcibly: thus the greater number of the extraneous particles will be got rid of. Those which remain lodged in the membranes must be speedily removed by those artificial means which have been already enumerated. If entropion is the cause of the inflammation, the eyelashes are either plucked out, or completely destroyed by removal of their roots. The inflamed organ should be carefully protected from the stimulus of strong light; the patient is to be placed in a darkened room, and the eye protected by a thin green shade. The shade, however, may be worn too long, so as to induce an extremely weak and tender state of the organ.

If there be good grounds for believing that the incited action has been caused by suppression of any discharge, that should be encouraged to return, and the cause of the suppression must be avoided. If a gonorrhœa have been suddenly arrested by the employment of stimulating injections, these must be instantly discontinued; and some have even gone so far, in such cases, as to introduce bougies impregnated with gonorrhœal matter, in order to procure a renewal of the discharge. In cases of suppression of purulent discharge from the ears, or the surrounding parts, followed by external ophthalmia, a blister or sinapism should be applied in the neighbourhood of the part from which the discharge formerly issued. When the menstrual evacuation has been arrested, leeches and fomentations should be applied to the pudenda, or around the anus, and emenagogues administered internally; the patient should be placed in a quiet and well ventilated apartment, and kept free from any emotions of the mind; all noise and other sources of irritation should be studiously avoided.

If the incited action in the eye do not subside, as it often will not, on removal of the exciting cause, recourse must immediately be had to very active means for its subjugation; for in no other organ does inflammatory action proceed more rapidly to an unfavourable termination. By timely use of antiphlogistic means, those consequences of external ophthalmia, which we have already treated of, may be avoided; and, with respect to most of them, it is much better to prevent their occurrence, than combat them after they have been allowed to take place. The eye is more valuable to a great proportion of people than a limb; and the surgeon is very culpable if he be not master of this part of his profession, and able to undertake the management of every disease and accident to which the eye is liable. “In cases of inflammation the general treatment is the same; but each variety requires peculiar attention during the cure, depending on the structure and function of the tissue affected.”

In the _first stage_ of external ophthalmia, active antiphlogistic measures must be put in force. In full habits, and cases of intense action, general bleeding must be employed, even to fainting, from the veins of the arm or of the neck, or from the temporal artery,—and repeated, if necessary, according to circumstances. Blood is sometimes abstracted by cupping from the temples or the nape of the neck; but it is a painful and uncertain mode of emptying the vessels. Local bloodletting, in many cases, suffices to moderate the action; in all it is most beneficial and important, after the employment of general depletion. The application of leeches to the inner canthus is the most effectual method of abstracting blood locally, as at that point the venous return is made from the eye. If placed on the temples, they can produce very little benefit; if on the outer surface of the eyelids, ecchymosis follows, on account of the extreme looseness of the cellular tissue in that situation. Or the angular vein, at the inner canthus, may be opened with a lancet, and a considerable quantity of blood thereby abstracted from the seat of the disease. Leeches applied to the conjunctiva of the lower lid are sometimes advantageous; but leeching and scarification are more useful in the chronic stage: and the latter is injurious in acute ophthalmia. Saline purgatives, and antimonial medicines, a very material part of the antiphlogistic regimen, must not be omitted. Enemata, with occasional pediluvia, are much recommended by some Continental writers. In bilious habits emetics, followed by mercurial purges, will be found very useful. With respect to topical treatment, warm applications are found to afford decided relief in the first stage, and are, in consequence, generally used. By some, however, cold water, or water with vinegar, is applied from the first. Poultices, whether warm or cold, prove annoying from their weight. Warm fomentations, simple or anodyne, are preferable, and may be repeated according to the feelings of the patient; or the eye may be exposed to the steam of water.

When by these means the violence of the symptoms has abated, as usually happens in the course of a very few days, the organ must be gradually accustomed to its natural stimulus, light. The shade must be discontinued, and the room no longer darkened; and now leeching becomes of great service, while the evacuation is to be followed by gently stimulating or astringent applications, so as to produce contraction of the still dilated, though partially emptied, vessels. Various collyria may be employed for this purpose. Solutions of the sulphate of zinc, of muriate of mercury, of sulphate of alum, of acetate of lead, or of the lapis divinus—wine of opium—the citrine ointment, or the unguentum oxydi hydrargyri rubri, &c.—or stimulating vapours of various kinds. Camphor is a good addition to many of the applications. The collyria may be cold, or slightly warmed; and maybe dropped into the outer canthus, flowing over the eye, and escaping by the inner canthus, according to the natural course of the fluids of the eye; or they may be inserted at the inner canthus, the head being immediately afterwards inclined so as to allow the fluid to pass towards the external canthus; or they may be applied by means of an eyeglass. Warm fomentations, and other relaxing remedies, however useful during the first stage, are worse than useless, are hurtful in the highest degree, when the affection has passed into a chronic state; as also are antiphlogistic means, and exclusion of light,—remedies so essentially necessary in the first stage.

In ophthalmia, attended with profuse _purulent_ discharge, the structure of the eye is in great danger of being destroyed, from the intensity of the action, and its liability to extend to the deep parts of the organ; the most active practice is required from the first. Copious general depletion, ad deliquium, must be quickly had recourse to; and the patient must be freely purged, and kept in a state of partial nausea for some time, by exhibition of antimonials. After general bloodletting, the repeated application of leeches to the inner canthus is necessary, in order to empty sufficiently the vessels of the part. Where the chemosis is so extensive as to bury the cornea, as it were, beneath the folds of the swollen conjunctiva, sloughing of the transparent tunic is frequently threatened. In order to arrest this fatal result, much good is often obtained by division of the chemosis. A sharp-pointed bistoury is passed through the swollen membrane, and radiating incisions practised, commencing at the corneal margins, and directing them towards the circumference of the globe. Sometimes four or even five of such divisions are called for, while care is taken not to wound the sclerotic coat beneath. A considerable quantity of blood is sometimes lost by this procedure, and, the chemosis subsiding, the cornea is saved. Infusion of tobacco, solutions of acetate of lead, and nitrate of silver, æther and laudanum, have been used as applications to the eye from the very commencement of the affection; but the propriety of the practice appears very questionable. Blistering the nape of the neck proves highly beneficial, after the employment of the antiphlogistic measures; and in many cases it is necessary to keep up discharge from the blistered surface for some time. On subsidence of the violent symptoms, the swelled conjunctiva is to be attacked with escharotics and stimulants, as the nitras argenti, sulphas cupri, or various collyria: then only can such applications be advantageous; at an earlier period they must do harm. They repress the exuberant granulations which may have formed, or may be forming, on the conjunctiva of the eyelids, promote contraction of the dilated vessels, diminish the relaxation of all the tissues, and stimulate the now dormant action of the part into a healthy state of excitement. Gently stimulating collyria may be injected betwixt the lids, by means of a small syringe. In granulated conjunctiva, it is sometimes necessary to remove a greater or less part of the diseased membrane by escharotics, the knife, or scissors; and after this has been accomplished it is well to encourage bleeding to a slight extent. In removing part of the palpebral conjunctiva, care must be taken to avoid injuring the cartilage of the tarsus; and, in the lower lid, not to take away too large a portion, lest entropion should occur during cicatrisation. In hospital practice, the infected should be separated from the healthy; and promiscuous use of towels and sponges must not be allowed.

In _Purulent Ophthalmia of Children_, antiphlogistic means must be pursued, if the patient is seen during the first stage of the disease; but children do not bear depletion well. After the discharge is established, the surface of the eye must be kept free of matter, by frequent injection of a bland, tepid fluid; and stimulating or astringent collyria should be applied three or four times a-day.

When _Inflammation of the Cornea_ is established, it is exceedingly difficult to procure contraction of the vessels. Active antiphlogistic measures must be employed in the acute stage; and in the chronic, stimulant applications are to be had recourse to. As, however, corneitis is frequently kept up in its chronic form, from deficient constitutional power in strumous habits, strict attention must be paid to the diet and secretions of the patient. Mild mercurial alteratives, diaphoretics, and tonics combined, will often effect a cure, where all local treatment has been tried in vain. When a large plexus of vessels remain dilated on the part, the most effectual method of removal is to divide them, as they ramify on the sclerotic, by means of scissors, or a fine knife, and afterwards to employ stimulating applications.

The irritability of _ulcers_ on the cornea is diminished by the application of nitrate of silver, in solution or substance. If in solution, the application is used in the proportion of three to ten grains of the salt to the ounce of distilled water; if in substance, a portion, finely pointed, is gently applied to the sore, which may be afterwards besmeared with a little oil or simple ointment, in order to confine the action of the nitrate to the ulcerated part. It is not necessary, but, on the contrary, hurtful, to rub the caustic freely on the sore; a very slight application is sufficient to coagulate the secretions on the part, and form a covering for protection of the surface. In two or three days afterwards, when the temporary covering has become detached, and when the irritability of the sore has in consequence returned, it will be necessary to repeat the application, but not till then. On each application, and few are in general required, the sore is found reduced in size considerably. The collyrium nitratis argenti is very useful in many obstinate cases of affections of the eye and eyelids, the strength of the solution being varied, according to circumstances.

In _Albugo_ and _Leucoma_, proposals have been made for excising, scraping, or perforating the opaque part; but the cure by such means is worse than the disease, as a raw surface is left larger than the previous opacity, and the cicatrix which must inevitably form also occupies a larger space, and is equally opaque. Leucoma and Albugo are incurable diseases, though the opacities may become somewhat thinner, by natural processes, after the lapse of a long period. _Nebulæ_, however, are often removable. During the treatment of them, or, rather, before beginning to treat them, it is of the utmost importance to attend to the state of the surface of the eye, and of the lids and eyelashes. Stimulating substances may be applied in cases where the opacities are thin: powders of calomel, aloes, sugar, &c., have been blown into the eye; stimulating lotions or ointments are preferable; one containing the nitrate of silver, with the addition of a proportion of the liq. sub-acet. plumbi, is sometimes used with advantage. These, however, are often of no avail, unless the dilated vessels, when such exist, are divided, or a portion dissected out; afterwards stimulants will be efficacious, and must be used assiduously. The vessels may require to be divided again and again.

In _Ophthalmia tarsi_, gently stimulating ointments or lotions are to be used, and in obstinate cases much advantage will result from the application of blisters behind the ears and to the nape of the neck, or from the insertion of a seton in the latter situation. In children it is necessary to correct the state of the bowels, scarify teeth, and remove other irritating causes to which that tender age is liable.

_Sloughing of the Cornea_ should, of course, be prevented, if possible, by subduing the incited action before it has attained such intensity as to overcome the power of the part. The slough is slow in separating when the constitution has been much weakened; and sometimes tonics and stimulants, both external and internal, are required to hasten the process of separation. When the surface has at length become clean, the same treatment is required as to an ulcer of the part.

_Conical Cornea._—This deformity can scarcely be cured, nor can any optical contrivance effectually remedy the disturbance of vision. When the apex of the cone is opaque, the removal of the pupil to the circumference by operation affords the best chance of assisting the sight of the patient.

When _staphyloma_ is small, neither impeding the motions of the eye, nor preventing its being protected by the lids, no surgical interference is called for, as the loss or impairment of vision cannot be remedied, and as no other inconvenience than blindness is produced by the change of form in the part. But when the diseased cornea projects from between the eyelids the prominence must be diminished, on account of the deformity which it occasions, and in consequence of the eye being deprived of its natural protection of the lids, and being thereby exposed to constant irritation. In such cases it is necessary to take away a portion of the cornea, that the eye may be so diminished in bulk as to retract within the eyelids; the size of the part removed must be proportioned to the degree of protrusion. A cornea-knife is passed into the prominence, and carried forwards so as to transfix the part, in a direction from the external to the inner canthus; and by the knife being carried on, with its cutting edge looking downwards, a flap of the cornea is made. This flap is then laid hold of by means of forceps, and removed either with the knife or with scissors. The aqueous humour immediately escapes, and in most cases the crystalline lens and vitreous humour are also discharged. The eye consequently shrinks, and retracts within the palpebræ. The cut margins of the cornea soon assume a reddish appearance—they form granulations, the wound contracts gradually, and ultimately closes; but the eye is necessarily much shrunk, and totally useless as an organ of vision. Generally suppuration takes place, causing complete disorganisation of the parts; and the preceding inflammatory action may be so intense, and attended with so much constitutional disturbance, as to require active measures for its moderation. Deformity may be in a great measure removed by adapting an artificial eye to the shrivelled remains of the natural one. When it is necessary to remove only a small part of the cornea, the aqueous humour alone escapes, and during the cure of the wound the patient not unfrequently enjoys a tolerable degree of vision; but after the wound has completely closed, vision is again lost completely.

_Hydrophthalmia_, also, is a disease in which little hope can be entertained of materially benefiting the patient. In the slighter cases, in which no very annoying symptoms accompany the affection, vision may be improved by the use of optical instruments; mercurial preparations may be employed in moderation, with the view of promoting absorption of the superabundant fluid. When the disease has made considerable progress, temporary relief may be obtained from puncturing the cornea at its lower part, so as to discharge the accumulated aqueous humour; but a cure can scarcely be expected from such a practice, however often the paracentesis may be repeated. In the worst cases the pain is so excruciating, and the system so much disturbed by the local affection, as almost to warrant the destruction of the organ, in order to relieve the patient; but, after all, even such severe measures will most probably prove unavailing.

In _Exophthalmos_ the treatment must vary according to the circumstances which cause the protrusion of the eyeball.

_Of Internal Ophthalmia._—Inflammation of the internal parts of the eyeball sometimes supervenes on conjunctival inflammation, and then the distinctive characters of the two affections are not perceptible. When inflammatory action attacks the deep parts primarily, the external ciliary vessels ramifying on the sclerotic coat are seen, enlarged, shining through the conjunctiva; and, as they advance towards the clearer part of the eye, they form a zone of a pink colour, whose vessels run in a straight direction towards the margin of the cornea; but between the zone and the cornea a distinct white line is often interposed. Then large arborescent and reticulated vessels soon appear on the white part of the eye; and from their being more superficial than the first, and of a brighter hue, it is obvious that they belong to the conjunctiva. They also approach the clear part of the eye, and, if numerous, obscure the former vessels—as also the red zone and white line—for they pass over them, and reach the corneal margins, and often go beyond it, in continuous ramifications. The sclerotic, in consequence, assumes a pink-red colour, and the cornea becomes dim.

The iris may be primarily and principally affected, and, if so, the disease is termed _Iritis_; but in most cases all the other internal parts suffer more or less. The iris changes its appearance, becomes of a dusky hue, either in part or throughout, and red vessels are sometimes distinctly seen in it; from grey or blue it changes to a greenish colour, and when formerly black or brown it becomes reddish. The size of the pupil diminishes, and the contraction is often irregular, when the inflammatory action is intense. The iris swells perceptibly, and the pupil loses its dark colour, or is almost entirely closed, either from effusion of lymph, or from inflammation and consequent opacity of the crystalline lens and its capsule. The iris projects forwards, and diminishes the capacity of the anterior chamber; the pupil is irregular, and often assumes an angular appearance; and the irregularity becomes permanent from adhesion of the pupillary margin of the iris to the capsule of the lens, lymph being effused and organised, and forming a firm uniting medium between the parts. Occasionally adhesions form at the middle of the iris, and cause so great contraction as to give the pupil an appearance of being double. Of course irregularities of the pupil are most distinct when the part is dilated, either spontaneously or by the application of belladonna. Tubercles sometimes form on the iris, and not unfrequently it presents a granulated appearance. From the commencement of the inflammatory attack the patient feels great pain in the organ and in the forehead, and there is great intolerance of light. There is a feeling of tension of the eyeball, followed by deep throbbing pain increasing every instant. As the disease advances, the cornea is rendered opaque by the fulness of the chambers, and the aqueous humour becomes turbid and of a milky appearance; or lymph is effused into the anterior chamber, and floats about in flaky portions. Occasionally the vessels of the iris are so distended as to give way, causing effusion of blood into the chamber, often in considerable quantity.

More frequently, however, puriform fluid is deposited, occasioning the appearance termed _Hypopium_. The pus is either fluid or of a thick curdy consistence: when fluid and thin, it mixes with the aqueous humour, rendering it white and opaque; if of firmer consistence, it lodges in the lower part of the chamber, but changes its position, and mixes partially with the humour, on the head being moved; when dense and curdy, it remains separate from the humour, and its position is not altered by motions of the head.