Page:EB1911 - Volume 10.djvu/110

Rh conditions this leads to a similar inflammation in the other eye. This so-called sympathetic ophthalmitis is of a malignant type, causing destruction of the sympathizing eye.

The Retina.—Choroidal inflammations are generally patchy, various foci of inflammation being scattered over the choroid. These patches may in course of time become more or less confluent. The effect upon vision depends upon the extent to which the external or percipient elements of the retina become involved. It is especially serious when the more central portions of the retina, are thus affected (choroido-retinitis centralis).

A peculiar and grave pathological condition of the eye is what is known as glaucoma. A characteristic of this condition is increase of the intra-ocular tension, which has a deleterious effect on the optic nerve end and its ramifications in the retina. The cause of the rise of tension is partly congestive, partly mechanical. The effect of glaucoma, when untreated, is to cause ever-increasing loss of sight, although the time occupied by the process before it leads to complete blindness varies within such extraordinary wide limits as from a few hours to many years. The uveal tract may be the site of sarcoma.

The retina is subject to inflammation, to detachment from the choroid, to haemorrhages from the blood-vessels and to tumour. Retinal inflammation may primarily affect either the nerve elements or the connective tissue framework. The former is usually associated with some general disease such as albuminuria or diabetes and is bilateral. The tissue changes are oedema, the formation of exudative patches, and haemorrhage. Where the connective tissue elements are primarily affected, the condition is a slow one, similar to sclerosis of the central nervous system. The gradual blindness which this causes is due to compression of the retinal nerve elements by the connective tissue hyperplasia, which is always associated with characteristic changes in the disposition of the retinal pigment. This retinal sclerosis is consequently generally known as retinitis pigmentosa, a disease to which there is a hereditary predisposition. Besides occurring during inflammation, haemorrhages into the retina are met with in phlebitis of the central retinal vein, which is almost invariably unilateral, and in certain conditions of the blood, as pernicious anaemia, when they are always bilateral.

The optic nerve is subject to inflammation (optic neuritis) and atrophy. Double optic neuritis, affecting, however, only the intra-ocular ends of the nerves, is an almost constant accompaniment of brain tumour. Unilateral neuritis has a different causation, depending upon an inflammation, mainly perineuritic, of the nerve in the orbit. It is analogous to peripheral inflammation of other nerves, such as the third, fourth, sixth and seventh cranial nerves.

Diseases of the Conjunctiva.—These are the most frequent diseases of the eye with which the surgeon has to deal. They generally lead to more or less interference with the functional activity of the eye and often indeed to great impairment of vision owing to the tendency which there is for the cornea to become implicated.

Many different micro-organisms are of pathogenetic importance in connexion with the conjunctiva. Microbes exist in the normal conjunctival sac. These are mostly harmless, though it is usual to find at any rate a small proportion of others which are known to be pyogenetic. This fact is of great importance in connexion both with problems of etiology and the practical question of operations on the eye.

Hyperaemia.—When the conjunctiva becomes hyperaemic its colour is heightened and its transparency lessened. Sometimes too it becomes thickened and its surface altered in appearance. The often marked heightening of colour is due to the very superficial position of the dilated vessels. This is specially the case with that part of the membrane which forms the transition fold between the palpebral and the ocular conjunctiva. Consequently it is there that the redness is most marked, while it is seen to diminish towards the cornea. An important diagnostic mark is thus furnished between purely conjunctival hyperaemia and what is called circumcorneal congestion, which is always an indication of more deep-seated vascular dilatation. It also differs materially from a scleral injection, in which there is a visible dilatation of the superficial scleral vessels.

When a conjunctival hyperaemia has existed for some time the papillae become swollen, and small blebs form on the surface of the membrane: sometimes too, lymph follicles begin to show. The enlargement and compression of adjacent papillae give rise to a velvety appearance of the surface.

Hyperaemia of the conjunctiva where not followed by inflammation causes more or less lacrymation but no alteration in the character of its secretion. The hyperaemia may be acute and transitory or chronic. Much depends upon the cause as well as upon the persistence of the irritation which sets it up.

Traumata, the presence of foreign bodies in the conjunctival sac, or the irritations of superficial chalky infarcts in the Meibomian ducts, cause more or less severe transitory congestion. Continued subjection to irritating particles such as flour, stones, dust, &c. , causes a more continued hyperaemia which is often circumscribed and less pronounced. Bad air in schools, barracks, workhouses, &c. , also causes a chronic hyperaemia in which it is common to find a follicular hyperplasia. Long exposure to too intense light, astigmatism and other ocular defects which cause asthenopia lead also to chronic hyperaemia. Anaemic individuals are often subject to discomfort from hyperaemia of this nature.

The treatment of conjunctival hyperaemia consists first in the removal of the cause when it can be discovered. Often this is difficult. In addition the application of hot sterilized water is useful and soothing.

Conjunctivitis.—When the conjunctiva is actually inflamed the congested membrane is brought into a condition of heightened secreting action. The secretions become more copious and more or less altered in character. A sufficiently practical though by no means sharply defined clinical division of cases of conjunctivitis is arrived at by taking into consideration the character of the secretion from the inflamed membrane and the visible tissue alterations which the membrane undergoes. The common varieties of conjunctivitis which may thus be distinguished are the following: Catarrhal conjunctivitis,  Purulent conjunctivitis, Phlyctenular conjunctivitis, Granular conjunctivitis and Diphtheritic conjunctivitis.

However desirable a truly etiological classification might appear to be, it is doubtful whether such could satisfactorily be made. So much is certain at all events, that not only can identically the same clinical appearance result from the actions of quite different pathogenetic organisms, but that various concomitant circumstances may lead to very different clinical signs being set up by one and the same microbe. As regards contagion there is no doubt that the secretion in the case of a true conjunctivitis (i.e. not merely a hyperaemia) is always more or less contagious. The degree of virulence varies not only in different cases, but the effect of contagion from the same source may be different in different individuals. Healthy conjunctivae may thus react differently, not only as regards the degree of severity, but even according to different clinical types, when infected by secretion from the same source. There are no doubt different reasons for this, such as the stage at which the inflammation has arrived in the eye from which the secretion is derived, differences in the surroundings and in the susceptibility of the infected individuals, the presence of dormant microbes of a virulent type in the healthy conjunctiva which has been infected, &c. Many points in this connexion are very difficult to investigate and much remains to be elucidated. Contagion usually takes place directly and not through the air. Often in this way one eye is first affected and may in some cases, when sufficient care is afterwards taken, be the only one to suffer.

The treatment in all severer forms of conjunctivitis should be undertaken with the primary object in view of preventing any implication of the cornea.

Catarrhal conjunctivitis, which is characterized by an increased mucoid secretion accompanying the hyperaemia, is usually bilateral and may be either acute or chronic. Acute conjunctivitis lasts as a rule only for a week or two: the chronic type may persist, with or without occasional exacerbations, for