LECTURES ON

DISEASES OE THE IRIS.?No. III. By C.

Superintendent'of

Magnamara,

the Calcutta

Ophthalmic Hospital.

Iodide of Potassium has for many years been employed with such marked success in certain cases of syphilitic and rheumatic affections of the iris, and of almost every other fibrous tissue of the body, that it deservedly holds a high position among the reat our command. In the milder cases of inflammamedial

agents

tion of the iris of syphilitic origin, the iodide of potassium should be administered in five-grain doses, three times a day, in preference to mercury ; and in cases depending on a rheumatic

diathesis, it may be given in similar quantities before meals, and in addition, these cases will generally bo improved by a large tumbler of lime-juice taken two hours after breakfast. Turpentine has been extolled by surgeons of high repute as an invaluable remedy in cases of plastic iritis, and no doubt its administration is attended with advantage, especially after the pupil has been dilated with atropine; but the patient still complains of much pain in the eye, and the sclerotic and conjunctival congestion continue. A drachm of the oil of turpentine given three times a day certainly tends to allay these symptoms, but as turpentine is apt to cause strangury, I have lately prescribed the balsam copaiba with advantage in instances of this kind; a drachm may be given every six hours, but if the symptoms do not yield to this within forty-eight hours, there is no advantage gained by continuing its use. Opium is probably one of the most powerful and, at the at our command in the treatment In acute cases of either form of inflammation of the iris, it should be administered in full doses, probably for an adult one grain of opium every second hour would be about the dose required, until the patient is brought fully under its influence ; should he be in great pain when first seen, a'sub-cutaneous

same

time, beneficial medicines

of iritis.

injection of a quarter of a grain of morphia beneath the skin of the temple will be of service in procuring him rest, a point which cannot be too strongly insisted on in the treatment of all severe forms of iritis. The effects of the opium should be kept up until the pain and other symptoms of inflammation have begun to subside. Among younger patients, and in less urgent cases, it would of

course

be unadvisable to administer

quantity of opium above recommended ; the dose in fact must vary according to the circumstances of the case, its beneficial effects being far more marked ia acute forms of iritis than

the

in chronic As

or

sub-acute cases.

means

a

of

from which some

relieving the intra-ocular tension and pain, patients attacked with iritis suffer, it is neces-

and allow some of the aqueous sary to puncture the cornea, humour to escape. The point of a broad needle is to be thrust through the cornea into the anterior chamber, and when in this situation it is to be tilted over on its edge, a small

of the aqueous humour being allowed to escape by the the instrument, which may then be withdrawn from the eye, the wound in the cornea immediately closing and preventing any further escape of aqueous. Immediately after

quantity sides

of

this little

applied

operation, a pad the eyelids. It

over

aqueous humour be allowed

and bandage should be carefully is not advisable that the whole ot the

to flow out of the anterior chamber, the lens and inflamed iris would be thrust lorwards against the cornea, and anterior synechia would apt to result. "When making the puncture, care must be taken that only the

for in that

case

.Ttoe 1,

LECTTTEES ON DISEASES OE THE IEIS.?BY DE. C. MACNAMAEA.

1867.]

point of the needle is allowed to pass through the cornea, otherwise, as the aqueous humour escapes, the iris or even the lens may he wounded. This proceeding is often followed by marked relief to the patient, and in all instances in which the tension of the globe is decidedly increased, is imperatively called for. It may ho necessary to puncture the cornea on two or three occasions, at intervals of about thirty-six hours, the indications for a repetition of the operation being augmentation of the tension of the eyeball and increased pain in the eye. Leeches applied to the temple, and over the brow of an eye affected with iritis, will doubtless relieve the pain for the time, but not so speedily as the evacuation of the aqueous humour; and beyond relieving the pain, the beneficial effects of leeches are very doubtful. It is by no means advisable, therefore, to apply leeches simply because a patient is suffering from an attack of iritis, although ho may have great pain in the eye and other symptoms of acute inflammation. Should the individual happen to be a plethoric subject, with a full, hard, and quick pulse, half a dozen leeches may be applied over the afl'ceted eye with advantage, and the part should subsequently be well fomented with hotso as to encourage the flow of blood from the leech-bites. If this treatment appear to exercise a beneficial action on the disease, we may repeat it on the following day. Cases of this description are likely to be much benefited by a dose or two of and colocynth, followed by a black draught in the blue

water,

consideration The

directly

the

symptoms

from

which our

patient

may be

Atropine is an invaluable accessory in the treatment of all of iritis, for if we can only manage to keep the pupil dilated, it is impossible for synechia to form; besides which, when the iris is well contracted on itself, forming a narrow rim round the anterior a

chamber, state of

tt

perfect

a

remedy than atropine, pupil in iritis. Equal parts of extract of belladona, Indian hemp, opium, and glycerine, to which atropine has been added, forms a useful mixture, which may be smeared over the affected eye to relieve the ciliary neurosis. Poppy-head fomentations are often soothing to the patient, and whenever this is the case, they may be used with advantage five or six times a day ; if they do not relieve the pain, it is advisable

it follows that its blood-vessels cannot must in fact be emptied of

congestion, they

great extent.

rest

discontinue the fomentation. The diseased eye should be coa light pad and bandage, our object being not to apply pressure over the eye, but simply to keep the eyelids closed and the parts at rest; if at the same time the sound eye be protected a to

recovery than atropine does in cases of iritis; it enables us to secure the inflamed part absolute rest, it lessens the calibre of its congested, vessels, and it prevents the injurious consequences

vered with

which necessarily follow an attack of plastic or parenchymatous iritis, bv keeping the iris well away from the lens ; and lastly by lessening the vascular supply, and diminishing the amount of the secreting surface cf the iris, it controls the abnormal secretion of

short time. In the more acute forms of the disease it is often a difficult matter to bring the pupil under the influence of atropine, and it may be necessary to continue its instillation every three a

hours or oftener, for a period of five or six days, using a solution of two grains of atropine to a drachm of water. In some instances the atropine is unable to act, on account of the swollen and con-

by

green spectacles, the patient is often able to leave his dark room and enjoy the society of his friends, or even attend in part to his business. These are apparently trivial matters but are nevertheless well worthy of consideration, as tend to shade

the aqueous humour, and in this way lessens the intra-ocular under our notice pressure. If a case of iritis is fortunately brought before synechia have formed, or the structure of the iris has been

irreparably damaged, we may with safety rely upon atropine as being the most efficient curative means at our disposal; a lew drops of the solution of sulphate of atropine (strength of solution, sulphate of atropine one grain, water one drachm) should be allowed to run into tne eye every three or four hours, or until the pupil is fully dilated. If the pupil once become dilated under this treatment, we may confidently rely upon curing our patient in the course of

progress the disease may have

eye as an aqueous solution. Extract of Belladona is a less potent and is not to be relied on for dilating the

The inflamed tissue is also when under the influence of mydriatics, most important point in the treatment of all forms of a inflammation. I know of no remedial agent which directly places an inflamed structure in a more favorable position for their contents to

kept

or

none need be feared. Atropine may be conveniently applied in some cases, mixed with gelatine, in small tablets, or upon pieces of paper saturated with a solution of atropine, and then dried. A tablet or a piece of paper is to be applied on the conjunctiva of the everted eyelid; the eye may then be closed, and the lachrymal secretion dissolving the atropine, it becomes absorbed, as it would be if dropped into the

cases

remain in

to the form

and believe that

patients already weakened by pain, and it may be, mercury, leeches would be positively injurious, they should consequently be used with caution, and under any circumstances it is well not to rely much on their aid for the instance of

ameliorating suffering.

as

only evil effects likely to follow a prolonged use of granular conjunctivitis. Small clamps and such like

is instruments have been invented to prevent the solution of atropine from passing through the puncture into the nasal duct, as it is assumed the drug is absorbed by the mucous membrane of the nose, and may then produce its poisonous effects on the sysI have never seen any ill effects follow its use in this way, tem.

atropine

low diet at the same time being strictly enjoined: in fact the leeches will form a part of an antiphlogistic plan of treatment, but are not to be used with the idea of cutting short or influencing the inflammatory action going on in the In

gested state of the iris ; in these cases the prognosis must be unfavorable, but we should endeavour to reduce the inflammatory action, and then to set to work again with the atropine. It is advisable to keep the pupil dilated for some time after all acute symptoms have passed away ; in fact till the sclerotic zone of vessels has disappeared, and the balance of circulation in the iris has been restored. In many cases of iritis, the synechia formed are only partial bands of adhesion, existing between the iris and the capsule at certain spots, the remainder of the iris being sufficiently healthy to respond to the action of atropine; under these circumstances, the pupil in dilating assumes all manner of shapes, expanding in one direction, and being prevented doing so at another by the synechia. Atropine should be steadily and freely employed in cases of this description; the synechia are often broken through under its influence, and the existing iritis speedily subsides, and moreover the synechia being destroyed, subsequent attacks of iritis will probably be prevented. "While, therefore, employing the various means at our command for improving our patient's health, and, if possible, acting on the cause which has induced the iritis, we should invariably endeavour to dilate the pupil to its fullest extent with atropine, without any made.

pill morning,

iris.

145

or

they

relieve the irksomeness of solitary confinement, which is too often the patient's doom if he remains in a dark room ; by keeping up his spirits, we do much towards preventing his falling into a low state of health, which would react on the local

certainly

I

inflammation and very probably impede the patient's recovery. The conjunctivitis, which always attends iritis to a greater or less extent, may, as a general rule, be allowed to run its course, unless it is excessive, in which case it may be well to scarify the swollen tissue and thus relieve thechemosis. A strong solution of nitrate of silver should be painted over the skin of the lids if are puffy and swollen, but it is not advisable to drop astringent lotions into the patient's eyes in cases of this kind.

I they

Constitutional symptoms, such best

treated

istration of

as intermittent fever, will be by hot-baths and sudoriflcs, but the adminopium tends greatly towards allaying fever of

THE INDIAN MEDICAL GAZETTE.

146 this

and relieving the 'obstinate vomiting occasionally with among patients suffering from iritis. The state of the bowels must be attended to, but because an individual is suffering from inflammation of the iris, to administer purgatives is a

kind,

met

unphilosophical proceeding, and often tends to complicate by disordering the digestive organs, which have frequently nothing to do with the iritis. "With regard to the use of stimulants and food, these are doubtless powerful agencies In a case placed at our command, in the treatment of disease. of iritis occurring in the instance of a plethoric individual, purgatives, starvation, and in fact an antiphlogistic treatment most

matters

is called for; but avast number of cases of iritis are of an asthenic amount of stimulants, good wholetypCj and require a moderate some food, and fresh air; in some cases we shall have to ^minister bark and ammonia, together with wine and beef-tea. It is impossible to lay down positive rules on these matters ;

nothing but observation and experience can guide one to a right conclusion; but as one man's powers vary from another in appreciating these circumstances, so will the one differ from the other in his success in practice. It would be as absurd to starve, salivate, and leech a patient, simply because he was suffering from parenchymatous iritis, as it would be, without consideration, canula into another's abdomen, because to run a trocar and it had increased rapidly in circumference within a short period. Counter-irritation, in the form of blisters to the temple, is comparatively useless in the active stages of iritis, but subsequently it is very beneficial, especially when the patient complains of dimness of vision, depending on haziness of the posterior layer of the cornea ; it is surprising what a very slight amount of opacity in this situation interferes with the correctness of vision, but by the aid of a succession of small blisters applied to the temple, the cloudiness gradually fades away, as it does in instances of keratitis. Supposing the patient's sight is affected in consequence of synechia, or bands of adhesion which have formed in the pupil, we must, in the lirst instance, endeavour to dilate the pupil by a persevering use of atropine, as I have already described; but in case the adhesions cannot thus be broken down, it will be necessary to resort to one of two operations, corelyasis or iredectoiny, our choice depending on the nature of the case. In instances where the pupil is only partially closed, or when the synechia bind the iris down to the lens at one or more points, a portion of its margin remaining free, if atropine fails to dilate the pupil and break down the bands of adhesion, we must proceed to perform the operation of corelyasis, as recommended by Mr. Streatfield (Ophthalmic Hospital Reports, 185960) ; for adhesions involving more than the margin of the pupil) and when the iris is completely tied down to the lens, wc must resort to iredectomy. The steps to be taken in performing the operation of corelyasis are as follows :?A solution of atropine having been dropped into the patient's eye three or tour times a day, for a week prior to the operation, we shall be able to discover those parts of the margin of the pupil which are still free from adhesions, by the pupil dilating at these parts and as our object is to insert a small spatula through an opening of this kind, between the lens and iris, and then carefully break down the synechia with a spatula, so as to free the iris from the capsule, it necessarily follows that we must carefully study the geography of the individual's iris, when under the influence of atropine, before we attempt to operate. The patient is placed in the recumbent position, and chloroform having been administered, Weiss's stop speculum is adjusted, and the surgeon, standing behind his patient, secures with a pair of toothed forceps a fold of conjunctiva close to the margin of the cornea, and a sufficiently large puncture having been made in the cornea, as nearly as possible opposite to the principal synechia, a Streatfield hooked spatula is inserted through the wound into the anterior chamber, and the blunt extremity of the instrument is passed under tlie margin of the ,

.

pupil,

[June 1,

and between the iris and

1867.

lens, (its point being carefully

directed away from the latter) and far enough beneath the iris, to enable us, by a slight lateral and traction movement, to lift the iris away from the lens and break through the synechia. The hook near the extremity of the instrument is very useful,

enabling

tear

through any tough bands of adhesion, which elongate themselves when force was applied, probably eluding our best efforts to reinstate the pupil. It is necessary to be careful not to wound the lens during the performance of this operation; but if the patient is fully under the influence of chloroform, and if too much is not attempted at a time, the capsule of the lens usually escapes uninjured. Those synechia only opposite the point of puncture in the cornea should be broken through daring our operation; for instance, if the adhesions we propose dividing are situated on the inner side of the pupil; but if there are also synechia above and below the pupil, we should make our puncture in the outer part of the cornea, and passing the spatula through it, insert the point of the instrument beneath the inner margin of the pupil, breaking down the adhesions in this situation, and leaving those above and below for another operation, for the us

to

would otherwise

division of which the puncture will be made in tho upper and lower part of the cornea respectively. It is a point of some importance in operating, that the aqueous humour be preserved

escaping till after the synechia are broken through ; this may generally be avoided by having a spatula just large enough to fill the puncture made in the cornea. It is impossible to 3ay down any precise rules as to the distance from the margin of the cornea at w hich the opening should be made. The chief point to attend to is, that we select a spot which will most readily admit of our passing the spatula through it, in such a direction as to avoid the lens, and enable us to break through the existing synechia. The operation of corelyasis is equally applicable to cases where the pupil is partially closed by organized plastic formations; the false membrane may be broken through as above described. The same remark applies as to the instance of anterior synechia. The after-treatment is very simple. Atropine must be dropped into the eye three times a day, so as to dilate the pupil as far as possible, and the eye is to be kept closed with a pad and bandage for ten or twelve days ; we may then proceed to break through any remaining adhesions, if the irritation caused by the former operation has subfrom

sided.

\f

(To

be

continued.)

Lectures on Diseases of the Iris.-No. III.

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