Chapter XIII: Introduction (10)

The attendants should be carefully instructed as to the importance of the care and the contagious nature of the pus.

Antisepsis and cleanliness here is more essential, effective and exclusive than in any other disease of the eye. Wisdom in the use of antiseptics is a strong point in the armamentarium of every progressive osteopath.

Trachoma

This disease is known as =granular lids= or =granular conjunctivitis=. Although the germ has not been discovered, we know this is an infectious disease. A roughness and hypertrophy of the conjunctiva develops. There is development of follicles or granulations. Later these products are absorbed and cicatrization of the tissues follows.

=Cause.=—Trachoma is found most common in Egypt and Arabia. It spreads easily in crowded institutions. It is in many instances a mixed infection with the Morax-Axenfeld bacillus, Koch-Weeks bacillus and the gonococcus.

=“Trachoma bodies”= have been discovered which are claimed by some to be a causative factor in the disease. These small bodies are not found in all cases however.

Spinal lesions of the cervical and upper four thoracic vertebræ will disturb the blood and nerve supply to the eye which will predispose to the disease should some of the virus or germs of trachoma be present. In practically all these cases there is tenderness if not an actual twist at the second and third thoracic.

=Symptoms.=—A small boy came to our clinics complaining that his left eye was smaller than the right. No inflammation or swelling was prominent. The eye looked normal except slightly smaller than the right. On turning the lid granules in the fornix of that eye were readily noticed. Trachoma had a good start. The tissues were so hypertrophied in that region that the eye could not be opened quite as wide as the other one, hence the impression that that eyeball was smaller. The granulation often develops so insidiously that the victim may have the disease for months before he realizes he has a bad eye. When symptoms appear there may be photophobia, lachrymation, gluing of the lids from a scanty secretion, pain, and blurring of vision. The granules are gray, translucent and roundish under the conjunctiva.

Hypertrophy increases to a certain height when cicatrization and contraction begin. The duration may be years. The more the hypertrophy the longer the duration and the greater the contraction. (Note here that treatment should be directed toward combatting the hypertrophy by establishing circulation).

=Sequelæ.= I merely mention the sequelæ here: pannus, ulceration of the cornea, trichiasis, dystrichiasis, entropion, ectropion, symblepharon, xerosis, corneal opacities. For the explanation, pathology and treatment of these sequelæ not covered in this treatise, see any good works on diseases of the eye as Weeks, Fuchs or De Schweinitz.

=Treatment of Trachoma.=—In reporting cases of trachoma treated and cured by osteopathy we should be sure of our diagnosis.

The treatment is antiseptic, hydrotherapeutical, osteopathic and operative. A saturated solution of boric acid should be used. Argyrol 20% is good if there is much secretion. Nitrate of silver 2% and copper sulphate are still used in some cases to advantage as claimed by some physicians. The osteopath should count on careful cleanliness.

Hot compresses over the eyes are often very agreeable.

Operations are often performed for trachoma. The granules are rolled out with Knapp’s roller forceps, and other methods.

=Grattage= is practiced with some wonderful results. It is done as follows: Get some fine sand paper and cut it in strips about one-half inch wide by three or four inches long. Put it in alcohol in a vessel for ten to fifteen minutes. Pour off all the alcohol except a few drops that will cling to the vessel by capillary attraction. Touch a match to the residue. This will burn just enough to make the sand paper absolutely sterile without burning the latter. Put the patient under somnoform. Use a small artery forceps to grasp the edge of the eyelid, roll the lid back over the artery forceps to expose all granulations clear to the fornix. Use a protector to the eyeball. Now with the sandpaper quickly scrape or curette away all of the trachoma bodies and granulations. Repeat the process on the other eye if it is involved. Wash out well with a saturated solution of boric acid and bandage the eyes for a few hours. This will cause considerable swelling and inflammation. Use cold applications and keep the eyes disinfected. I have seen some very good results from this method.

=Osteopathic.=—Following the sand paper operation a thorough treatment of the cervical and upper dorsal region would add considerably to the rapidity of the patient’s recovery and sense of well being. General tonic treatment is of special benefit in nearly all trachoma cases as they are subnormal in their general health.

One form of technique which has been used by myself and others to advantage in these cases is as follows: Sterilize the fingers carefully, lubricate with vaseline or K. Y. the forefinger of the right hand. With the left hand raise the upper lid and introduce the forefinger of the right hand with the thumb above. Catching the lid between the thumb and finger squeeze and massage the whole structure clear to the fornix as thoroughly as possible. Repeat the process on the other eye.

A technique used by Dr. Edwards of St. Louis is as follows: After sterilizing and lubricating the forefinger lift the lid and introduce the finger as far as possible into the orbit pushing the fornix back into the orbit. This stretches all the tissues around the fornix, opening up a better conjunctival and palpebral circulation. The ciliary vessels and nerves are stretched and stimulated. It is rather surprising to one who has not tried it, how far the finger can be introduced into the orbit.

One set of nerves that should be especially studied and considered in trachomatous conditions is the cere-brobulbo-spino-sympathetic-ciliary arc. This has already been elaborated. All spinal lesions should be carefully diagnosed and corrected.

Dr. T. J. Ruddy’s third finger eye instrument is very useful in these conditions in restoring normal circulation about the orbit.

See that the nose and throat are normal.

Phlyctenular Conjunctivitis

By some this disease is considered an =eczema= of the conjunctiva. This will at least enable us to get an idea of the conjunctival pathology. What is said of phlyctenular conjunctivitis applies largely to its corresponding disease of the =cornea-phlyctenular keratitis=. Scrofulous ophthalmia is applied by some because so many of these phlyctenular patients have =scrofula=. Herpes conjunctivæ is used as a name because of the small blisters or blebs that form in the beginning stage. Little red eminences develop near the limbus (sclerocorneal junction). They are cone shaped, slightly elevated about the surrounding tissue. There may be one or several, usually not more than one or two. After a few days the cone breaks and on top appears a small gray ulcer. There is further breaking down and the cone disappears leaving an ulcer on level with the conjunctiva. Vessels are congested about it. There may often be noted an area of small vessels, fan like in shape, running from the outer region of the conjunctiva to the ulcer or phlyctenule.

=Etiology.=—This is a disease of frequent occurrence in children, mostly among the poor classes. Such things as eczema, dirt, adenoids, scrofula, rhinitis, malnutrition, abuse of tea and coffee and exanthematous disease are mentioned by oculists as causes. I have no doubt any or all these conditions predispose to phlyctenular conjunctivitis.

De Schweinitz in “Diseases of the Eye,” 1916 edition, p. 242, says: “The exact cause of ocular lesions, or phlyctenular eruption, has not been determined.”

I have met Dr. De Schweinitz and heard him lecture on the eye. I consider him one of the best eye specialists in the country. His experience and study with the eye dates over many years and his book has gone through eight editions. He is professor of ophthalmology in the University of Pennsylvania; Ophthalmic Surgeon to the Philadelphia Polyclinic Hospital, the Philadelphia General Hospital etc., etc.

His opinion represents the summary of the investigation of the ophthalmic profession the world over and through all the past down to the present time. “The cause of phlyctenular conjunctivitis is not known.”

=Bacteriology.=—At times in the ulcers have been found the staphylococcus pyogenes aureus and albus. They are also found in a normal conjunctival sac. They could not with logic be taken as a causative factor; at least they would be only secondary.

If oculists and other students of the eye all had a good deep osteopathic vision to throw light upon these problems many causative factors would take on a new meaning. Such supposed causes as have been mentioned, e. g. eczema, adenoids, rhinitis and malnutrition may easily be secondary to the osteopathic lesions. Micro-organisms may be enabled to act because of trophic and circulatory disturbances to the conjunctiva through disturbed nerve connections from lesions in the cervical and upper dorsal regions. Herpes zoster is purely a trophic nerve disturbance manifestation on the skin as blebs or blisters with more or less neuritis. Any lesion that would affect the integrity of the function of the fifth cranial nerve might easily manifest itself as herpes of the conjunctiva.

We believe the osteopathic lesion is primary and fundamental in the causation of most of our phlyctenular conjunctivitis. Of course insanitation, scrofulous diathesis and the exanthemata play their role. A good diagnostician should figure out the relative importance. The history, onset and examination will usually eliminate these conditions.

=Symptoms.=—Lachrymation, photophobia, blepharospasm and injected vessels are the chief symptoms. There is pain as well as fear of light. The child fights examination.

The attack subsides in ten to fourteen days unless there is multiplicity of blebs. Some patients have repeated attacks for months or years. Many of these cases in medical clinics keep coming for months with repeated attacks. Never leave out careful osteopathic treatment.

=Prognosis.=—This is favorable for a final cure. If there should be multiple blebs and frequent recurrence and the cornea is invaded, the prognosis is not good for perfect sight. The pathology goes deep enough to affect Bowman’s membrane of the cornea disturbing the substantia propria. This causes a macular condition of the cornea which impairs sight.

=Therapy.=—Diet should be bland; the eyes should be protected from irritants; yellow oxide ointment should be used in the eye once a day or 10% argyrol. The ointment is preferred. Moist warm compresses on the eye are comforting. A boric acid wash in almost all conjunctival trouble is good. If there is much irritation giving a suspicion of iris involvement a drop of atropine ½% should be used. The general regimes of living should be regulated.

Osteopathic treatment should be directed toward building up the general health and correcting all lesions, especially that may have a specific bearing on the eye trouble. Such lesions will be found more often at the first, second and third thoracic, but may be anywhere from there to the occiput.

Vernal Conjunctivitis

This disease is known by many as =vernal catarrh= or =spring catarrh= of the conjunctiva. It is a chronic inflammation which sets up changes in the conjunctiva and tarsus. This disease may be confused with trachoma unless one observes closely. There are broad flat papillæ on the conjunctiva. These papillæ may readily be taken for granulations. They are larger than the granules in trachoma. They somewhat resemble the arrangement of cobble stones. The conjunctiva has a bluish-white filmy appearance called by some, milky shimmer.

The disease was thought at first to appear only in the spring, hence the name vernal. Many cases continue through the year with exacerbations in the spring. It occurs more often in boys. Both eyes are attacked. It may heal and leave no trace. It may last from four to twenty years.

=Causes.=—Almost all works on the eye say the cause is not known. De Schweinitz says, “Definite information in regard to the cause of this disease is lacking.” There may be a micro-organism which has not been discovered.

I wish to call the attention of the osteopathic profession to the great fact that there are numbers of diseases of the eye as well as of other parts of the body about which the medical profession are entirely “at sea.” This gives valuable ground for scientific research by our profession.

My experience with this disease is not sufficient for me to speak with any positiveness or finality as to its cause. The altered trophic parts and the very chronic condition existing leads me to the firm belief that we will ultimately find the cause as a mechanical lesion affecting the trigeminal or sympathetic (or both) nerve connections. Glare of light and local irritants act only as secondary causes. Nasal disease may be associated and act as a cause.

=Symptoms.=—There is photophobia, some mucus, slight pericorneal injection, redness of the conjunctiva of both the bulb and lids; that of the lids is thickened and of dull pale color due to sub-epithelial hyaline thickening. The fact that there is no pannus, and flat granulations and recurrence with spring, marks it from trachoma.

=Prognosis.=—Under medical treatment it is unfavorable; may last twenty years. Slight opacity of the cornea may develop.

=Treatment.=—The eyes should be protected with dark glasses. Cold compresses give some relief. Boric acid is good as a wash. Yellow oxide of mercury ointment may be of service as an antiseptic and alternative. If nasal disease exists, it, of course, should be treated according to indications. Fundamentally the lesions in the spine in the cervical and upper dorsal regions should be specifically corrected. When enough cases of vernal catarrh have been observed and treated osteopathically much light and benefit will be brought to bear upon this obscure and intractable disease of the conjunctiva.

Diseases of the Cornea

Anatomy

The cornea with the sclera forms the outer coat or tunic of the eye ball. The cornea is in front and forms one-sixth of the envelope. It is a segment of a smaller globe than that of the sclera. It is about 12 mm. horizontally and 11 mm. in the vertical diameter. Its thickest part is at its junction with the sclera where it is about 1 mm. This junction is called the limbus. The cornea is inserted into and rests on the sclera like a watch crystal. The fibers of the cornea pass continuously into the sclera, however. The normal cornea is transparent. Most morbid changes of the cornea cause a diminution in this transparency. In old age a narrow gray line near the corneal margin makes its appearance. This is known as the =arcus senilis=. There is a little strip of perfectly clear cornea between the arcus senilis and the limbus.

The cornea has five layers. These layers should be noted with care, as in wounds of the eye, foreign bodies in the cornea and ulcerations, the results depend much upon which layers are affected.

1. The =anterior epithelium= consists of pavement cells of several layers. This layer of the cornea may be damaged or scratched off in large patches and still it will heal readily leaving no trace of the injury.

2. The =anterior elastic lamina= or =Bowman’s membrane= is very thin and homogeneous; it is just beneath the epithelial layer and forms a resisting sheath to prevent damage to the next layer.

3. The =stroma= or =substantia propria=. This layer composes about nine-tenths of the cornea. It is composed of minute connective tissue fibers between which lie some stroma cells or corneal corpuscles. Some of these cells are fixed while others are motile. The motile ones are the white blood-corpuscles which move about in the lymph passages of the stroma. They increase in any irritation of the cornea.

4. =Descemet’s membrane.= This is a tough homogeneous hyaloid membrane back of the stroma. When the stroma is diseased and breaks down Descemet’s membrane may be sufficient to prevent a puncture of the cornea.

5. The =Endothelial layer= is a single layer of flattened cells which coat the posterior surface of Descemet’s membrane.

The margin of the cornea is in relation with three membranes, the conjunctiva, the sclera and the uvea (iris and ciliary body). In a disease of the cornea, a conjunctivitis, an iritis or a cyclitis is easily started.

The cornea contains no vessels. It is nourished by imbibition. At the limbus there is a rich network of marginal loops supplied by the anterior ciliary vessels. From these loops the blood plasma passes into the stroma of the cornea.

The nerves of the cornea come from the ciliary nerves and the nerves of the bulbar conjunctiva. These are from the trigeminus and the sympathetic. The nerves extend numerously in the stroma passing forward through Bowman’s membrane into the epithelial layer. This makes the cornea very sensitive to the touch.

Examination of the Cornea

Note the size and form. Both may be modified by morbid processes. Note the surface with regard to curvature, evenness and smoothness. In =keratoconus= the curvature is greatly increased. Noting the reflex images in the cornea and comparing these with those of a normal cornea will show any variation in curvature. Also any =unevenness of the surface= may be noted by the irregularity or distortion of the images. Uneven spots on the cornea may be =depressions or elevations= from loss of substance; =wrinkles or collapse= from lowered tension.

If the smoothness or polish of the cornea is lost it looks like glass that has been breathed upon or greased. It is lusterless and dull.

Note also the transparency of the cornea and determine the form, extent and density of the opacity; whether it is diffuse or in spots; in the deep or superficial layers. A magnifying glass should be used in the study of opacities. According to the density of the opacity of the cornea it is known as a =nebula= or a =nebulous opacity=, a =macula= or a =leucoma.= The nebula is the least noticeable and the leucoma is the densest opacity. A leucoma is a condition of complete opacity. The cornea looks white.

Defects in the corneal epithelium may be made to show clearly by the use of a 2% solution of fluorescein which stains them green.

Note the sensitiveness of the cornea by touching it with the end of a thread, a little cotton or a shred of paper. The sensitiveness is diminished or lost in glaucoma and some other diseases.

Diseases of the Cornea

Almost all diseases of the cornea have some form or degree of inflammation. =Keratitis= is the word generally used for inflammation of the cornea. In order to aid clearness in discussion there are various subdivisions of keratitis made by different writers. Suppurative and non-suppurative are the principal types. In =suppurative keratitis= there is always some destruction of corneal tissue which on healing leaves an opacity with partial loss of vision. Germs gain entrance into the tissues usually from the exterior and some form of ulceration results.

The following classification is taken from Fuchs:

=Suppurative Keratitis.=—(1) Ulcer of the cornea; (2) Serpiginous ulcer; (3) Keratomalacia or Xerosis; (4) Keratitis neuroparalytica.

=Non-suppurative Keratitis.=—(A) SUPERFICIAL: (1) Pannus, or keratitis with blood vessels; (2) Phlyctenular, or keratitis with vesicles. (B) DEEP: (1) Parenchymatous or interstitial.

In keratitis there is first an infiltration or the increase of cells in the substantia propria or the parenchyma of the cornea. This is the exudate of the inflammation. It causes the cornea to look more or less dull or cloudy. The disease may clear up at this point or go on to suppuration. If it clears up it is known as =resorption=. If the lamellæ of the substantia propria are not destroyed by the process, resorption takes place with no loss of substance. The exudate disappears and there is perfect transparency of the cornea again. There may be slight damage of the stroma preventing perfect transparency. Resorption of the exudate may not be quite complete which may become partly organized and left permanently fixed in the cornea. Cases resorbing without destruction of the stroma are forms of the non-suppurative keratitis group.

If the stroma breaks, suppuration occurs. This is the second stage and is associated with a localized destruction of the cornea. These cases are known as =suppurative keratitis= or =ulceration of the cornea=. The disintegration begins in the most anterior layers of the cornea. A slight depression in the cornea can be noticed. The infiltration is all about the ulcer, getting less as it is more remote from it. If the floor and walls of the ulcer are foul with the infiltrate it is known as a =progressive= ulcer. =Sloughing= may continue to spread the ulcer.

If the cloudiness around it disappears and the ulcer acquires a smooth transparent base and edges it is known as a =retrogressive= or clean ulcer.

The disintegrated areas of the cornea may be replaced by newly formed tissue. This is the third stage or that of =cicatrization=. This new tissue is connective tissue. It is opaque, leaving a permanent opacity.

=Stages of keratitis=:

=Suppurative.=—(1) Infiltration; (2) Suppuration and (3) Cicatrization or Reparation. The suppuration is progressive or retrogressive.

=Non-suppurative.=—(1) Infiltration; (2) Resorption.

In the diagnosis of a keratitis one should look at it very carefully. A loupe which has thick plus sphere lenses will magnify the field and may be of great assistance in observing closely the condition.

If the cornea is clouded and dull the trouble is recent and if there is no loss of substance it is an infiltrate (first stage). If there is loss of substance it is a progressive ulcer (second stage.)

If the surface is lustrous but cloudy the trouble is an old one and if there is loss of substance it is a retrogressive ulcer; if no loss of substance it is a cicatrix.

Frequently blood vessels grow in from the margin in ulcerations of the cornea. This is usually a process of healing of the corneal ulcer. The advent of the blood vessels is favorable. After healing the blood vessels gradually disappear. They never entirely disappear from large cicatrices.

In some cases new vessels accompany the inflammatory process and like the exudate are a part of the clinical picture of the disease as in parenchymatous or interstitial keratitis. Pannus also has vessels. They are not in the cornea but are in new tissue deposited upon it.

=Symptoms appearing in keratitis=:

1. =Ciliary injection= or a red area encircling the cornea. If the keratitis is severe there will be considerable inflammation of the conjunctiva which may hide to some extent the ciliary injection.

2. =Iritis or iridocyclitis= may set in. The iris and ciliary body are in such intimate relation with the cornea that these structures are very subject to involvement in any severe keratitis. With iritis would come danger of =synechiae= or adherence of the iris to the anterior surface of the lens.

3. =Hypopyon.=—In suppurative keratitis there is some exudate into the anterior chamber of the eye. This exudate drops to the bottom of the chamber and looks like pus had gathered in the bottom of the aqueous. This condition is called hypopyon.

4. Other symptoms which are frequently prominent are =diminished vision=, =pain=, =photophobia=, excessive =lachrymation= and =blepharospasm=. Edema of the lids and conjunctiva may occur.

Intelligent treatment of keratitis of course is based upon the exact conditions present. Great care in diagnosis and treatment should be exercised.

Ulcer of the Cornea

Inflammation of the cornea sets in from some cause. There is an infiltrate into the substantia propria. A spot becomes cloudy and the surface over it becomes dull; at this point the epithelium breaks down or exfoliates and the loss of substance in the parenchyma is the beginning of an ulcer.

=Cause.=—The cause may be constitutional or local. The causes usually thought of from the medical standpoint may be noted in such books as “Diseases of the Eye” by De Schweinitz or Weeks. I wish especially to call attention to the fact that there is frequently a primary and underlying cause of corneal ulcers not mentioned in any medical texts, i. e. the osteopathic lesion. By this I mean more than the spinal lesion although the subluxation lesions that result from the occiput to the fourth dorsal are of most importance. Any tension or change of tissue in the cervical region that may interfere with perfect freedom of circulation of blood to the tracts and centers in the cord, is to be considered. The osteopath of course should take into consideration all causes primary and secondary and govern himself accordingly.

=Symptoms and Course.=—There is a gray area surrounding the ulcer at first, also the floor is grayish in color. In this condition it is known as a =progressive= ulcer or a =foul= or =unclean= ulcer. This cloudiness or gray area may increase in size and the ulcer keep spreading, or it may go deeper even to perforation of the cornea.

Some ulcers advance or spread on one side and heal on the opposite side so that they creep along on the cornea—these are the so-called =serpiginous ulcers=.

With corneal ulcers there is irritation, pain, photophobia and increased lachrymation. There is usually some ciliary injection which is an indication of involvement of the iris and ciliary body. If iritis occurs there is contraction of the pupil with slow reaction. =Hypopyon= may develop. With iritis and the exudate there is likely to be adhesions between the iris and the lens known as posterior synechia.

A few corneal ulcers are asthenic and do not have irritative symptoms and yet are dangerous.

When the ulcer begins to heal it is called =retrogressive=. Dead tissue is cast off; other tissue becomes transparent from resorption. We have a =clean= ulcer. Symptoms disappear and cicatrization begins. Vessels extend to the ulcers and soon it is leveled up with the corneal surface. Cicatrization may leave it slightly below the corneal level or above it.

If there should be perforation of the cornea from the ulcer there may be =complications=, e. g. keratocele, loss of aqueous, dislocation and expulsion of the lens, intra-ocular hemorrhage, flattening of the cornea, fistula of the cornea, glaucoma, intra-ocular suppuration, prolapse of the iris into the opening, etc. These complications and sequelæ that occur occasionally will not be considered here.

After healing is complete by cicatrization there is opacity of the cornea in proportion to the depth and size of the ulcer. In months and years of time there is some clearing of the opacity so that small superficial opacities may become invisible.

=Treatment of Corneal Ulcers.=—Most ulcers of the cornea are quite amenable to proper treatment and the prognosis is favorable. Neglect or wrong treatment is very dangerous. The treatment is local and constitutional. Often the ulcer is kept going by unwholesome constitutional conditions.

=Local Treatment.=—This varies according to the stage of the ulcer, whether progressive or retrogressive. In a progressive or foul ulcer if due to trauma any foreign bodies should be removed. If the ulcer is a result of pathology of the conjunctiva it is of primary importance to treat the conjunctival condition.

In mild cases of ulcer a dressing over the eye with atropine ½% to keep the pupil dilated is sufficient local treatment. The bandage protects the eye from bright light and other environment and the atropine puts the iris and ciliary body at rest preventing complications and giving nature her best chance to work.

If the ulcer is rapidly progressive, warm compresses an hour or two a day are good; iodoform sprinkled on the ulcer or actual cautery may be used. In the retrogressive stage (clean ulcer) healing has begun and we desire to get as near as possible a resistant transparent cicatrix. Yellow oxide ointment is useful at this stage.

=Osteopathic.=—The local measures just mentioned are not incompatible with osteopathic theory or practice. They are merely adjunctive in getting nature’s reaction toward normalization, as also are hot and cold applications. Osteopathy comes in now in a most important and fundamental way with the constitutional and specific lesion treatment. The =bulbo-spino-sympathetic-ciliary arc= has been mentioned and explained. Through this important nerve connection with the eye, profound and wholesome effects on the eye may be gotten by osteopathic treatment. Frequently lesions of the occiput, cervicals and upper dorsals will affect the integrity of the ocular structures through disturbances of nerve and blood supply.

The stomach, bowels, liver and kidneys should be carefully noted in corneal ulcers. Poor circulation, indigestion, constipation and auto-intoxication may have an important bearing on the recovery of the ulcer.

Xerosis or Keratomalacia

This is a disease of the eye in children due to insufficient nutrition of the cornea. Hereditary influences, depleting diseases and lesions affecting the trophic nerves to the eye are causes.

=Treatment= consists of building up the nourishment of the child, correction of lesions and careful dieting. Hot applications to the palpebral region helps to bring the blood supply to the eye for local effects.

Keratitis Neuroparalytica

This disease is due to a paralysis of the 5th cranial nerve. The cornea becomes slightly cloudy. The epithelium gradually sloughs away. An ulcer may or may not form. Pain and lachrymation are absent because of paralysis of the trigeminus. There is usually ciliary injection.

=Treatment.=—The most important treatment for this unfortunate condition is manipulation to restore the integrity of the 5th cranial nerve and the blood supply to the eye. Cervical, spinal, nasal, nasopharynx treatment should be given. Spring the inferior maxilla.

A drop of atropine (1%) should be used locally because of the ciliary injection. Warm compresses used locally will help. The healing usually leaves some opacity of the cornea. Keep the eye bandaged to protect the cornea.

Pannus

This form of keratitis is superficial and is characterized by the formation of blood vessels in the cornea. It is caused by some irritative influence. Most often it is a complication of trachoma.

If the irritation can be removed the vascularity gradually recedes, leaving a clear cornea unless the deeper structures of the cornea have been involved.

Phlyctenular Keratitis

This disease is an involvement of the cornea with an eczematous process similar to phlyctenular conjunctivitis. There is more likely to be ciliary injection and iritis, in which case atropine should be used. The treatment is the same otherwise as for phlyctenular conjunctivitis.

Parenchymatous or Interstitial Keratitis

This is shown by a diffuse inflammatory infiltration of the substantia propria of the cornea. Part or whole of the cornea of one or both eyes may be involved. Very fine blood vessels may invade the deep structures of the cornea.

=Cause.=—Syphilis, tuberculosis, rheumatism, diabetes and rachitis are systemic diseases found back of this trouble.

=Symptoms.=—Irritation, lachrymation, photophobia with ciliary injection are the chief symptoms.

=Treatment= must be local and constitutional.

Locally atropine should be used. Dark glasses should be worn or the patient must be kept in a dark room. Treatment to the trigeminal nerve and tissues of the orbit should be given.

Constitutional treatment should be spinal with the idea of arousing all the forces of the body to greater activity. Careful dieting should be followed according to indications.

The infiltration and blood vessels will ultimately disappear. Sometimes enough may remain to cloud the vision.

Diseases of the Iris and Ciliary Body

The iris and ciliary body have the same blood and nerve supply. That is, they are supplied by the same set of vessels and nerves. For this reason it is practically impossible to have an iritis absolutely independent of a cyclitis or some inflammation of the ciliary body. If the iris is the primary seat of the trouble there are certain symptoms that may indicate such a state. However, when we are treating the iris or diagnosing conditions of the iris we must remember that the ciliary body is very likely more or less involved and may be the primary seat of the trouble.

In =iritis= there are some symptoms which are caused from the hyperemic condition of the eye, such as a slight change in color. The pupil becomes rather inactive, there is some ciliary injection with photophobia, lacrymation and pain. In case of an exudate in the iris there may be thickening, and the exudate in the anterior chamber of the eye will form a =hypopyon=. Sometimes the small vessels will break and there will be a little bleeding which will be mixed with the debris in the bottom of the anterior chamber. This is known as hyphemia. There are likely to be adhesions between the iris and the anterior capsule of the lens known as posterior =synechia=. The pupil is more or less irregular. If atropine is dropped into the eye to dilate the pupil, parts of the edge of the pupil will be adhered while the other parts dilate making it very irregular.

In case of cyclitis there is an exudate from the ciliary body into the posterior chamber. This may cause a total adherence of the iris to the crystalline lens. With the ophthalmoscope, opacities in the vitreous may be noticed. These are exudates. The tension of the eye is liable to increase a little at first but as the exudates absorb there is more or less softening. Vision is low. Also in cyclitis there is ciliary injection, photophobia, lacrymation and pain, similar to that of iritis. Pressure on the eye ball will reveal a very tender condition around the sclerocorneal junction or over the area of ciliary injection.

The causes of iritis, cyclitis or iridocyclitis frequently are systemic conditions and infection such as syphilis, rheumatism, gonorrhea, tuberculosis, infectious diseases and metabolic changes, it may be of traumatic origin or sympathetic. Fuchs says “There are many cases of iritis for which no cause can be discovered and therefore which cannot be placed under these causes.” We agree with him and advance the theory of cervical and upper dorsal lesions or trouble in the sinuses, nose, nasopharynx or throat. No doubt osteopathy can throw some important light on the causes of diseases of the iris and ciliary body. The nose and throat should be examined in all these cases.

=Treatment.=—Atropine must be used in the sore eye to put the iris and ciliary body at rest and dilate the pupil to draw it back from the lens so that adhesions may not form. Warm compresses will give much comfort. Sweating should be brought about. All fluid should be reduced to a minimum. Diet should be very moderate and the bowels kept unusually free. The eye should be protected by dark goggles. Thorough treatment of the neck and upper dorsal region with attention to the nose and throat should be given. Constitutional treatment should be given according to the indications mentioned under causes. If annular synechia or total posterior synechia form or there is atrophy of the eyeball operative work may be needed. Also for injuries, tumors, anomalies and so forth of the iris see the latest medical works on this subject.

Diseases of the Choroid

The =choroid= is the vascular tunic of the eye. With the iris and ciliary body it forms the =uvea=. The iris and ciliary body are rich in nerve terminals and when inflamed; pain is a prominent symptom. The choroid has no sensory nerve terminals. When it is involved alone; pain is not present however severe the pathology. Embryologically Descemet’s membrane is a part of the uvea. When the uveal tract is diseased we frequently note symptoms of a descemetitis as a turbidity of the anterior chamber and spots on Descemet’s membrane. When one part of the uvea is inflamed the tendency is to pass to the other parts because of the intimate blood supply.

Choroiditis

There are many forms of choroiditis given by writers according to the clinical picture and the pathology.

=Symptoms.=—No pain is experienced unless there are complications. Vision is altered in some degree. The use of the ophthalmoscope may reveal opacities in the vitreous. Pigmentation spots and exudation may be noted in the fundus. In disseminated choroiditis spots of exudate appear in the fundus which go on to atrophy, leaving irregular circular light patches.

=Treatment.=—In all forms of choroiditis careful diagnosis of constitutional conditions should be made and treatment given according to indications.

Nasopharynx and orbital treatment as outlined under manipulation for diseases of the eye should be given.

Rest and protect the eyes. Secure free elimination.

Panophthalmitis

By injury or otherwise pathogenic germs are introduced into the eye. The trouble begins as a =suppurative choroiditis= and rapidly spreads to all the eye structures. The vitreous chamber becomes filled with pus.

=Symptoms.=—Pain is severe and sight is lost early. The conjunctiva and lids are much swollen. There is a mucopurulent discharge. The cornea becomes gray and may slough. In about two weeks the inflammation subsides and the globe passes into atrophy.

=Treatment.=—Elimination must be thorough. Spinal treatment for keeping up strength. Cervical, upper dorsal and nasopharynx treatment for the eye. Moist hot compresses to the eye. Operation, incision for drainage, or evisceration may have to be performed.

Sympathetic Ophthalmia

The other eye may become inflamed by the process from the panophthalmitis passing around through the circulation or the continuous structures. All symptoms of a general inflammation appear and vision gradually diminishes.

=Treatment.=—In panophthalmitis of one eye always watch the other eye closely. If it becomes irritable or shows any signs of being affected the diseased eye should be promptly removed, especially if vision is lost in that eye. If no irritation occurs, continued conservative treatment of the panophthalmitis may result in a subsidence of the disease without the well eye becoming affected.

Sympathetic inflammation rarely develops earlier than a month after injury to the exciting eye. Sooner than that or even a few minutes after injury there may be some signs of sympathetic irritation and the symptoms continue with no evidence except a slight circumcorneal injection. It should be treated like iritis. A thorough toning of the system by spinal treatment should be given. Order a limited diet. Secure free elimination.

Glaucoma

Glaucoma is essentially an increase in the intra-ocular pressure. All other symptoms of the trouble may be traced to this condition.

In =Primary Glaucoma= the increase in pressure sets in without any discoverable antecedent disease of the eye.

In =Secondary Glaucoma= the increase in pressure is due to some other disease of the eye. It is a symptom, a complication or accessory and is confined to the eye diseased.

Primary glaucoma affects both eyes, but not always at the same time. Fuchs says primary glaucoma constitutes about 1% of all eye diseases. It is often mistaken for iritis or iridocyclitis and treated with atropine which is contraindicated. It may be regarded as beginning cataract and time lost in expecting it to become ripe. These delays and wrong treatment have caused much blindness.

Palpation with the finger or the use of the tonometer may readily detect any increase in tension. A correct diagnosis must be made early and proper treatment instituted if vision is to be saved.

=Primary glaucoma= may or may not have signs of inflammation. If the tension rises suddenly inflammatory symptoms develop (acute) while if the increase in tension develops gradually these symptoms are lacking (simple).

=Acute primary glaucoma—Symptoms.=—First stage, rise in tension, vision obscured, sees a colored ring around lights, cornea dull, pupil dilated and sluggish, some ciliary injection. The attack may clear up for a day or for weeks. Gradually the symptoms become permanent after repeated attacks. Second stage, when the attack comes there is much pain, visual power fails rapidly, may be edema of the lids and chemosis of the conjunctiva, all symptoms become much exaggerated, the cornea becomes cloudy. After a violent attack the vision is more or less permanently damaged. Third stage, after many attacks the optic nerve becomes excavated and atrophy takes place.

Simple Primary Glaucoma

=Symptoms.=—Tension comes gradually; no inflammatory signs; pupil somewhat dilated and sluggish, the cornea may look slightly smoky. With the ophthalmoscope a cupped disc may be noted. There is gradual diminution of sight, which begins by contraction of the field.

There are many theories advanced as to the cause of intra-ocular tension in glaucoma. (Fuchs, Weeks, De Schweinitz).

=Treatment.=—Eserine is used instead of atropine. The object is to contract the pupil and draw it away from the side wall of the eye ball so the sinus (Schlemm’s canal) and the pectinate ligament (the filtering angle) may become free. The good effect of this is more marked in inflammatory glaucoma. In simple primary glaucoma miotics do little good.

Reports from osteopathic treatment of this condition have been favorable in a number of cases. Careful manipulation of the structures of the orbit with the finger or with Dr. Ruddy’s third finger eye instrument is good in restoring better circulation of the lymph and blood. Special attention to the venous drainage should be given. Treat the points of the fifth nerve, the nasopharynx and cervical region, spring the jaw. Treat second dorsal.

Have the patient avoid strong emotions or excitement. Keep the bowels free and use only a very bland diet.

Iridectomy is considered the best operation in glaucoma.

In the treatment of secondary glaucoma the other diseases or complications must be considered in conjunction with the foregoing treatment.

Diseases of the Lens

Opacities or Cataract

=Symptoms.=—Beginning opacities can best be recognized with the ophthalmoscope. Advance opacities can be seen at a glance with the naked eye.

Vision is disturbed according to degree and location of the opacity. If the opacity is in the center of the lens and the periphery is transparent they see better when the pupil is dilated. When the opacities are in the periphery of the lens they see better by day. Muscæ volitantes and polyopia are present until increasing opacity closes up all clear areas shutting out these visual perversions.

There are many clinical varieties of cataracts which may be studied in works on ophthalmology.

=Causes.=—Some interference with the nutrition of the lens accounts for the condition. Heredity is supposed to play a part in some cataracts. Rickets, convulsions, traumatism, old age, some drugs (ergot), inflammation of iris, ciliary body and choroid are given as causes. Cervical and upper dorsal lesions and disease of the throat, nasopharynx and nose will interfere with perfect circulation and drainage of the orbit, and may well have much to do with many idiopathic cataracts.

=Treatment.=—Many cases have been reported cured by osteopathic measures. Correct lesions and treat to establish free nerve force and circulation of blood and lymph to the orbit. Manipulation of the orbital tissues and mild vibration of the bulb are measures of value. More hope may be held in symptomatic, toxic, secondary and progressive cataracts. The process may be stopped and in many cases there is hope of a clearing.

Diseases of the Retina

The retina lines the back part of the eye ball. It comes forward to the ora serrata. It consists of ten layers which have been demonstrated microscopically. One layer of it passes over the ciliary body and back part of the iris to the pupil. The fibers of the optic nerve spread out over the retina. The point of entrance of the optic nerve is the papilla. It is to the inner side of the posterior pole of the eye. The retinal vessels emanate there. The macula lutea is the yellow sensitive spot at the posterior pole of the eye. The fovea is the center of the macula. The rods and cones constitute the external layer of the retina. This layer is the light perceiving stratum. For vision to be perfect all the other layers must be perfectly transparent. The visual purple is a chemical substance in the rods that gives the retina a purplish-red color. The light shining into the eye forms images which are converted into nervous stimuli by chemical action of the visual purple and by physical changes and fibrillations in the rods and cones.

Retinitis

=Symptoms.=—The ophthalmoscope must be used in diagnosis. There is at first cloudiness of the retina; the outlines of the papilla become indistinct. We may note light patches of exudates. The vessels are more tortuous and often there are hemorrhagic spots. Opacities in the vitreous due to the exudate may be seen. Vision is disturbed in proportion to the inflammation. Weeks or months are required for recovery. Atrophy may set in and cause blindness.

=Cause.=—Many general diseases are found back of this trouble, e. g. albuminuria, diabetes, leukemia, syphilis, gout and arteriosclerosis. Idiopathic cases occur with none of these diseases present, which gives a field for osteopathic research.

=Treatment= should be directed against the general disease when present. For local effects treatment should be given to all the centers and localities that affect the trophism, nerve supply and circulation to the eye. Protect the eye by dark glass or confinement to a dark room and complete rest. Keep the bowels free and produce diaphoresis.

Optic Neuritis

This disease when manifest in the eye ball is called papillitis. If back of the bulb it is =retrobulbar neuritis=.

=Symptoms of papillitis.=—Pupils are dilated and sight diminishes. The color of the papilla is altered to a white, reddish or gray and may show extravasation of blood. The papilla is swollen (choked disc), the arteries are thin and the veins are engorged. It takes months for the inflammation to clear. Atrophy is likely to occur.

=Causes.=—Brain diseases are the most frequent cause, e. g. tumors. Syphilis, febrile diseases, nutritive disturbances, lead poisoning, heredity and growths in the orbit are cited as causes.

=Symptoms of Retrobulbar Neuritis.=—There is little or no change in the papilla. The diagnosis must be made mostly from the way the vision is affected. The rule is a central scotoma in the field of vision. The first colors to disappear are red and green. In the acute form there is quick disturbance of vision. The eye looks normal outside and shows practically no change inside.

=Cause.=—Toxemia, cold, influenza; nasal, nasopharyngeal and sinus disease (ethmoids), and infectious diseases are causes. Idiopathic inflammation of the optic nerve is noted by most oculists. Here the profound effects of spinal lesions upon the eye adds some important light.

=Treatment of Papillitis and Retrobulbar Neuritis.=—In each individual case the treatment requires consideration of the causal factor. There may be required constitutional treatment in many cases. In others the cause may be found in the nose, nasopharynx, or spine. Effort should be made to remove the lesion in each case. Diaphoresis will aid in acute stages.

Atrophy of the Optic Nerve

There are many causes for this condition such as optic neuritis, meningitis, acute infectious diseases, locomotor ataxia, arteriosclerosis, nasal disease, syphilis, traumatism, alcoholism, exposure, embolism of the central retinal artery, diabetes and poisoning. Diagnosis must determine the original cause.

=Treatment.=—I have mentioned conditions in the nose as frequently accounting for various eye troubles. If these atrophies of the optic nerve can be gotten early, many of them will be influenced very favorably by osteopathic treatment. Spinal treatment to direct the circulation to the area of the orbit at the base of the brain is beneficial. Regulation of the patient’s diet, habits, methods of living and so forth is important. Excessive mental strain, excessive sexual intercourse and stresses of every kind should be prohibited. Special treatment should then be given according to the causal factors entering into the case.

Eye Strain and Its Reflexes

For the subject of refraction and refractive errors such as the different forms of hypermetropia, myopia and astigmatism the reader is referred to the many excellent works on ophthalmology which cover these subjects quite thoroughly. They are only used here in the relation to eye strain and its reflexes. The osteopathic logic here given should be combined with a reading of the refractive errors in such works as Fuchs, Weeks, De Schweinitz and others.

Asthenopia

=Eye strain, weak sight or asthenopia= embraces the group of symptoms dependent upon fatigue of the ciliary muscles or of the extraocular muscles.

There are three varieties of asthenopia. (1) Retinal or nervous, (2) muscular and (3) accommodative.

The symptoms are headache—frontal, fronto-temporal or fronto-occipital. It may extend into the neck between the shoulders. Eye balls may be tender, diplopia at times, may be photophobia, lachrymation, congestion of the eye, itching and burning of the lids.

=Accommodative Asthenopia.=—In this form the ciliary muscle is fatigued. The cause is usually overuse of the eye when hyperopia and astigmatism exist; sometimes in myopia or presbyopia.

=Treatment.=—In this form the treatment is the proper fitting of glasses and improvement of the general health.

=Muscular Asthenopia= is due to tiring of the extraocular muscles, usually the internal rectus. This may result in a phoria or a non-paralytic squint.

Ametropia may exist but asthenopia may come even in emmetropia due to overuse of the eye.

=Treatment.=—Correct ametropia if present, with glasses. Exercise the weakened muscle. Correct the nerve supply to the weak muscle. Treat cervical and upper dorsal. Manipulate tissues of the orbit. Spring the jaw. Correct any nose and throat pathology.

=Nervous, Neurasthenic or Reflex Asthenopia.=—The cause is supposed to be some functional disorder, more often found in females. May be due to too dim or too bright light, overuse of the eyes. Hysteria may follow ametropia.

=Treatment.=—Often the treatment is troublesome and the case is very obstinate according to old school methods. Rest, hygiene, general health and habits are looked after. The cause must be found or the treatment cannot be specific.

These are the different forms of eye strain as ordinarily classified. Now as we study the reflex symptoms from these and attempt to trace out the reflexes from an osteopathic point of view, we may find some more definite causes of these conditions and consequently some methods of treatment not found in standard text books might naturally suggest themselves.

Reflex symptoms that have been traced to eye strain by ophthalmologists are as follows:

Constipation, indigestion, heartburn, nausea, vomiting, nervous attacks, fear of impending calamity, irritability, despondency, insomnia, restless sleep, epilepsy, nervous twitchings and enuresis. All these symptoms have been seen to disappear after eye strain was corrected. There is no absolute way of proving that all these symptoms have existed because of eye strain. The existence and disappearance of some of them at the time of treatment for eye strain may be a coincidence. It is evident that eye strain in varying degrees may produce a train of symptoms similar to many above mentioned.

A patient, nervous, anxious, uneasy, and despondent, constipated, and having some indigestion, showed on examination contractures and tenderness at the third dorsal. It was found he was suffering from eye strain from overuse of glasses that were too strong for him. The eyes were refitted. He was wearing a

(R)+4.50 D. S. = +.50 cyl. Ax. 180.
(L)+4.50 D. S. = +.50 cyl. Ax. 90
for close work and a (R)+2.00 D. S. = +.50 cyl. Ax. 180
(L)+2.50 D. S. = +.25 cyl. Ax. 90
for distance. The new glasses were—Reading—
(R)+3.00 D. S. = +.25 cyl. Ax. 180
(L)+3.00 D. S. = +.25 cyl. Ax. 180
Distance:
(R) + 1.50 D. S. = +.25 cyl. Ax. 180
(L) + 1.50 D. S. = +.25 cyl. Ax. 180

He was fitted two years previously. At that time the stronger glasses were correct. Eyes change more or less constantly, especially between the ages thirty-five to fifty-five years. When glasses are fitted, a weak ciliary muscle after a rest may become stronger and allow weaker glasses to be worn.

If a young person is fitted for myopia, in a few years he may discard his glasses as presbyopia develops. A person fitted correctly, who has a strong ciliary muscle may not be able for awhile to see as well with the glasses as without them. After they are worn awhile the ciliary muscle will cease its efforts to accommodate so much and the glasses give the desired effect. In some cases the doctor’s reputation to fit glasses properly may suffer at the hands of such people who sometimes refuse to take glasses, or after getting them refuse to wear them.

In the case of the man just mentioned a refitting quieted the nervous symptoms—he became more cheerful and ceased to worry. Indigestion and constipation improved. The soreness and contractures were overcome in a few treatments.

Now let us ask the question, why is it that eye strain will cause nausea and vomiting? Also why will indigestion affect the eyes by causing “spools” in the vision?

A little osteopathic logic, based as it always is or should be, upon anatomy and physiology, may throw some light on this subject. No doubt every one of us has demonstrated many times clinically that indigestion from overeating will cause soreness and contractures at the third and fourth dorsal, the nerve center in the spine for the stomach.

The reflexes between the viscera and the eye are complex and difficult to follow. In giving the probable course of the nerve reflexes from the optic nerve to the third nerve Dr. Louisa Burns suggests the following: “The nerve elements of the retina start the impulse; it passes over that portion of the optic nerves which enter the anterior quadrigeminates, the cells of the quadrigeminates where the impulses are coordinated, then by axons of these cells to the lateral or viscero-motor nucleus of the third nerve, thence to the cells of the ciliary ganglion, and by the non-medulated (sympathetic) fibers of these, the short ciliary nerves to the non-striated muscles concerned, viz: the ciliary muscle, some fibers of the levator palpebral and the sphincter of the iris.”