July 1,
LECTUEES ON DISEASES OP THE IEIS.?BY DE. C. MACNAMAEA.
18G7.]
that already prescribed in other forms of inflammation of the iris ; but we frequently meet with complications in instances of this description, arising from the lens having been injured, together with the iris. Under these circumstances the capsulo
ORIGINAL COMMUNICATIONS/
is often
LECTURES ON DISEASES OF THE IRIS.?No. IV. Bx C. Macnamara, Superintendent of the Calcutta Eye Infirmary.
but it becomes necessary to resort to iridectomy, otherwise the communication between the chambers of the eye
being occluded, an accumulation of fluid takes place in the posterior and vitreous chambers of the eye, which is certain in time to produce destructive changes in the retina. In these cases of closed pupil, the iris often bulges forwards towards the cornea from the pressure of the aqueous fluid behind it, but its pupillary border, being bound down to the lens, cannot be thrust forward in this way, and appears as it were in a pit(funnel-sha ped). Numerous proceedings have been advocated for the relief of this state of things, among which operations for the formation of an artificial pupil hold a prominent place, but it may safely be affirmed that an iridectomy made behind the upper section of the
cornea
is the correct line of treatment to
be pur-
exceptional cases, where the cornea is opaque m this situation. Iridectomy embraces all the advantages of an artificial pupil, and, in addition, has many valuable properties Of its own, not the least of which is, that it tends greatly unless in
to lessen the chances of recurrent iritis. It may therefore be affirmed that in instances of synechia, or closed pupil, which cannot be broken through by the aid of mydriatics or
safely the
operation of corelysis,
we
must resort to
iridectomy,
ex-
about one-fourth of the upper section of the iris. In this class of cases, the sooner the operation is performed the better : it is by no means necessary to wait till pain and irrita-
cising
tion in the eye have subsided, for in fact these symptoms are probably kept up by the synechia, and, if we wait till the inflammation has entirely passed away, the chances are that the integ-
rity of the deeper
tissues of the eye will have been
destroyed
in
the meantime. The amount of sight that the patient may possess
ought not to influence us as to the necessity of iridectomy; the central portion of the pupil may be clear, and yet no communication may exist between the chambers of the eye, and under these circumstances, although the patient may see tolerably well, we
perform iridectomy ;'on the other hand, perception of light, it is almost useless operating with an idea of improving the sight, for it is more than probable that detachment, or other destructive changes in the retina, which iridectomy cannot possibly influence, will have taken place. In cases where the iris bulges prominently forwards towards the cornea, indicating the collection of a considerable quantity of fluid in the posterior chamber, iridectomy is les3 likely to be successful than if the iris is in its normal position ; must not hesitate to if the patient has no
are still further reduced if we can make out a central opacity in the capsule of the lens,*a condition indicative of detachment of the retina. There may be some little difficulty in removing a portion of the iris in cases where it is swollen, from the pressure of
these chances
the
products
of
inflammation,
or
has
undergono atrophy.
Under
these circumstances, Yon Graefe remarks : "I employ straight pu-
pillary forceps with sharp teeth," which, instead of following ordinary direction, I apply to the iris somewhat perpendicularly. According to my experience, such an instrument is of very great service under these circumstances." (Page 284, Graefe on Iridectomy, New Sydenham Society, 1859. The general principles upon which we should conduct the treatment of a case of traumatic iritis, differs in no respect from the
and
the lens substance
swells, becomes
presents
corelysis,
sued,
perforated,
the iris, keeps up violent irritaopaque, and, by pressing upon tion and inflammation of the part. Whenever a case of this itself to our notice, it is well to remove the lens kind
As I before remarked, in cases when the pupil is entirely closed by false membranes, or its margin is wholly bound clown to the lens by synechia, we cannot perform the operation
of
165
at once ; the patient should be placed under the influence of chloroform, and a Weiss's stop-speculum having been adjusted, the surgeon should make an opening through the upper portion of the sclerotic as if for iridectomy ; about a fourth of the iris be removed should be excised,' and the lens must then and there X either by a scoop, or, if very soft, by means of a Bowman's suction instrument ; a few drops of a strong solution of atropine
dropped into the eye, and the case treated as one of ordinary linear extraction. The success of this operation depends upon the promptness with which it is undertaken ; if the surgeon attempts palliatives, such as leeches and the like remedies, in the hope of reducing the inflammation, the chances are, that his opportunity will slip away, and general inflammation and, it may be, abscess of the globe will supervene; whereas if iridectomy is at once performed and the lens removed, the patient will be saved much suffering, and with the aid of a lens will probably regain a very fair amount of vision. Occasionally a chip of steel, or some such foreign body gets lodged in the iris, causing violent inflammation ; if the lens has not been wounded, we may succeed in extracting a foreign body of this kind with a pair of canula forceps, or I do not hesitate to make a free opening in the cornea, and introduce a pair of iridectomy, or small forceps of the kind, and securing the offending body, remove it from the eye. Should the lens have been also involved, it is advisable to perform an iridectomy, including the foreign body, in the portion of the iris excised, and then "are to be
t
extract the lens as above described. I have already stated that degenerative
changes in one eyeball may, by sympathetic irritation, affect the other eye, causing an insidious form of iritis, or irido-clioroiditis, which generally advances steadily, ending in total blindness, unless wo can remove the source of irritation, that is, the primarily
diseased
eyeball. Ibido-choeoiditis.
Irido-clioroiditis, often described as cycilitis or inflammation of the ciliary body.?It is evident from the anatomy of the parts that iritis must be very apt to extend to the ciliary body ; in fact wo can hardly conceive a case of severe inflammation of the iris existing, without the ciliary processes becoming more I shall not, however, dwell or less involved in the disease. of in cases of the kind, form this irido-clioroiditis, because, upon we shall have distinct indications of the existence of iritis, aud. if acquainted with the more prominent symptoms of inflammation of the ciliary body, the diagnosis of the case can present I shall confine my remarks, therefore, to the no difficulty. features of inflammation of the ciliary more characteristic body, contenting myself with observing, that as disease going on in the iris is likelj to spread backwards, so inflammation commencing in the ciliary body, will often extend both to the iris and the choroid. In mild cases of iritis we are sometimes perplexed as to the very great impairment of vision from which our patient suffers, the state of the iris, aqueous, and cornea, being insufficient to
account for the symptoms. Under the circumstances, our suspicions should be aroused as to the existence of complications in the ciliary body, inducing opacity of the retina and haziness of of sight, the visual the lens. If, in addition to the
impairment contracted, and there is pain on pressure over region of the ciliary body, we may be almost certain that field is also
the we
THE INDIAN MEDICAL GAZETTE.
100 have to deal with
most
a
insidious,
but
Irido-choroiditis may be
destructive,
form of
conveniently
described under three
serous, and parenchymatous, or suppurative form of the disease. In plastic irido-choroiditis the patient complains of pain in the made over the region of the eye, increased on pressure being bo.lv, and in some instances he suffers from intense ciliary
heads?the
plastic,
ciliary
neurosis. In severe cases there is always more or less intolerance of light. The pupil responds but slowly, if at all, to the stimulus of light, and even strong mydriatics may fail to dilate it, in consedone to the
long ciliary nerves in their ciliary body. In acute cases there or less conjunctival congestion, and a zone of injected sclerotical vessels surrounding the cornea, but in milder instances this symptom may be almost wanting, specially if quence of the
injury
passage through is always more
the
case
be
a
and iris have
the inflamed
chronic one, and the circulation of the choroid adapted themselves to the altered condition of the
The fibrous structure of the iris and the cornea
parts.
are
yet the" patient complains of dimness of vision, the impairment of sight increasing after sunset, or in a dim light. On examining the eye with the ophthalmoscope, we shall find its fundus occluded by a cloudy condition of the vitreous humour ; this state of things of course acoften
perfectly healthy,
and
counts for the haziness of the field of vision from which the If the dissase is allowed to advance unchecked,
patient suffers. further changes
go on in the vitreous humour ; it becomes fluid' and small flocculent bodies may be seen moving in it; whenever the individual turns his eye from one side to the other, these
give rise to very distressing symptoms ; the instant the fixes his eye on an object, they fall forwards and obstruct the sight to a greater or less extent, and they are constantly whirling about before the patient's eyes. The field of vision subsequently contracts, detachment of the retina having flocculte
patient
occurred, and ultimately the patient's sight is entirely-destroyed.
pathological changes which produce these changes are^ ciliary body to those described as pathagnomic of plastic iritis; the vessels and fibrous structure of tho part become atrophied and destroyed, from organized plastic formations, and as these changes advance, the nutrition of the vitreous humour is impaired ; it degenerates, becomes first hazy, then fluid, and detachment of the retina results either from this cause, or from an extension of the disease to the choroid, and from serous effusion taking place between it and the retina. Serous irido-choroiditis is usually a most insidious form of disease, by no means of uncommon occurrence among ill-nourished and malarious-stricken individuals, such as many of the lower classes in all parts of the world must necessarily be; and consequently we have always cases of the kind attending the outpatient practice of the Calcutta Ophthalmic Hospital. In the early stages of serous irido-choroiditis, probably the only symptom from which the patient complains is dimness of vision ; everything appears as though seen through a mist, and these symptoms are more marked in a dim light, as for instance after The
similar in the
sunset: in fact so prominent a featuro is this of the disease, that instances of the kind are mistaken for night blindness. As the disease advances, the patient complains of opaque bodies floating about before his eves; these symptoms, as'above-mentioned, of tho vitreous hudepend on haziness, and subsequent
fluidity
There may be little or no pain in the eye, and the sclerotic zone of congested vessels may be entirely wanting. The pupil and responds but slowly, if at all, to tho stimulus of
mour.
frequently
takes a
considerable time to act,
light,
even under the influence of strong mydriatics. In other cases the serous effusion takes place rapidly, and under these circumstances tho intraand tension of the eyeball being occular
pressure,
suddenly
augmented, the patient experiences very great pain in the eye and .corresponding side of the head, the sight for tho time being
1867,
completely destroyed. In these acute cases, the poslayer of the cornea becomes hazy, its epithelium degenerating into opaque flocculent-looking masses, giving the cornea a speckled appearance, which is often so dense that the fibrous structure of the iris cannot even bo seen through it. Parenchymatous iriclo-choroiclitis is a most destru ctive form of disease, too often terminating in suppuration, in which case the pus formed in the ciliary body is apt to burst through and appear as an hypop ion in the anterior chamber. The symptoms induced by this disease are necessarily more acute than in either the plastic or serous forms of inflammation of the ciliary body. The patient complains of violent pain in the eye, extending to the temple and side of the face, and of almost complete loss of sight; great intolerance of light, and epiphora. The conjunctiva is deeply injected, and chemosis often exists ; the eyelids are not uncommonly puffy and swollen. The zone of sclerotic vessels is always present, depending as it does on the impeded state of the circulation going on in the ciliary body, but the injected chemosed sclerotic may be hidden by the inflamed and conjunctiva. Unless the disease be arrested in its early stage, the inflammation passes on to suppuration, and the pus bursts through the iris, and sinks down into the lower part of the anterior chamber. The sudden appearance of an liypopion, which, from the appearance of the parts, does not depend upon ulceration of the cornea, or suppuration of the iris, should at once lead us to suspect the existence of parenchymatous iridoehoroiditis. In these cases of suppurative cycilitis, it is evidently useless attempting to dilate the pupil, the functions of the nerves of the iris being in all probability destroyed for the time by the changes going on in the ciliary body. If the vitreous humour can be seen, it will be found hazy, and probably flakes of lymph will be noticed floating about in it. As the disease advances, in verymany cases, the sclerotic covering the region of the ciliary body undergoes degenerative changes ; it becomes thin and yields to the intra-occular pressure, and a staphyloma of some extent forms, often well nigh surrounding the eyeball, and occupying the region of the ciliary body. By degrees the choroid, and in fact all the tissues enclosed within the sclerotic become involved, and the disease but too frequently terminates either in atrophy, or, in the most acute cases, in abscess of the globe of the eye. The causes which give rise to irido-choroiditis are as numerous as those which induce iritis; syphilis, malaria, rheumatism, and the like affections are some of the more immediate influences which originate this disease ; in fact it so almost
terior
inflammation of the ciliary body.
[July 1,
?
often occurs as a sequence of iritis and vice versa, that the influence which excites the one form of local disturbance, is well nigh sure to induce the other. We sometimes see iridcchoroiditis
resulting from operations, or other injuries to the eye involving the ciliary body, and a most insidious and dangerous form of inflammation may without doubt occur in the ciliary body from sympathetic irritation propagated from the other eye, Unwhen undergoing atrophy or other degenerative changes. der these circumstances, the abnormal action in the ciliary body follows a very insidious course ; the patient frequently complains of little or no pain in the affected eye, but of gradually increasing dimness of vision, -which cannot be accounted for except from the presence of the other diseased eyeball, but on examining the best eye, wo shall at once discover the nature of the mischief going on ; the vitreous humour will appear hazy, and very probably opaque patches will be' seen floating about in it; these changes arising from sympathetic irritation propagated from the other eye, and affecting fhe circulation in the ciliary body and choroid, and consequently the nutrition of the vitreou3 humour under examination.
Treatment.?In considering the treatment to be adopted in cases of irido-choroiditis, we must evidently carefully examine all the circumstances of the case ; if arising from constitutional abnormalities, a different lino of treatment must be
July 1,
LECTURES OjST DISEASES OF THE IRIS.?BY DR. C. MACNAMARA.
1SG7.]
ployed to that which is necessary, if the disease arises from local or sympathetic irritation. In many instances of plastic and parenchymatous irido-choroiditis, we shall be able to trace the disease back to the effects of primary or inherited syphilis, -and
in
cases
of this kind
we
in iritis
must resort to mercury
as
recommended
arising from this cause. The mercurial vapour baths are particularly useful in these cases, not only on account of the specific action which the drug appears to exercise over syphilis. but also by means of the profuse perspiration the bath causes, and' which is frequently most beneficial in acute disease. In other cases of inflammation of the ciliary body depending on miasmatic influences, quinine must be administered; this is doubtless
a
very indefinite rule?for how
aro we
to
ascertain if
patient is suffering from the effects of malaria ? With regard to India, I doubt if every resident in the country, European or Native, is not tainted by the pernicious influence of miasma ; some of us appear, like the inhabitants of the Nepaul Terai, to become comparatively inured to the subtle poison, others resist it by the natural vigour of their vital powers, but among by far the majority of Europeans and Natives in India it may be slow, but deleterious changes are effected in the organism by malaria, consequently local inflammations, such as these we are now considering, may reasonably be surmised to be caused by miasmatic influences, if we fail to detect any other probable cause for the disease. Quinine, under these circumstances, should be employed ; it can seldom do any harm unless given in over-doses, and we may generally judge from its effects if it has any beneficial action on the disease, after using it for three or four days. As a general rule, five grains of quinine, three of sulphate of iron, and ten drops of diluted sulphuric acid may be given three times a day. In cases of neuralgia of the supra-orbital nerve, there is generally considerable hypersemia of the choroid and retina, and it may be a matter of some uncertainty whether the pain from which the patient is suffering arises from congestion of the tunics of the eye. or from simple neuralgia ; if from the latter, there is almost sure to be tender, a
pressure over the spinous processes of the first two cervi.' cal vertebra?; pressure exerted in this situation also often brings if affected with on a shooting pain in the supra-orbital nerve, ness
on
of the choroid,
by
pressure
increase of
no
symptoms arise from congestion pain in the parts would be induced
should the
neuralgia, whereas, applied
over
the vertebra;.
As I have before remarked, we are often consulted by patients suffering from a sub-acute form of serous irido-choroiditis, the chief and perhaps only complaint they have to make being indimness of vision, most marked after sunset ; the pupil
creasing sluwishly,
acts
but in other respects the eye may appear toler. we examine it with the ophthalmoscope, and
ablv healthv, until
humour. The majority of then discover opacity of the vitreous and the mercurial vapour cases are of syphilitic origin, a mixture conbath should be employed, but I also administer of mercury and taining the twelfth of a grain of bichloride in water three times a day; five of iodine of we
these
potash,
grains drugs
have to be continued for some time, but their beneficial action on the disease is often very marked indeed. Counin the form of a succession of blisters, or an issue these
ter-irritation in opened in the skin of the temples, are invaluable adjuncts the treatments of all forms of sub-acute irido-choroiditis. In acute cases,
opium
is
a
remedy
which we can never
safely
dis-
pense with ; it must be given in full and repeated doses, so as to ensure the patient's rest, and comparative freedom from pain. With regard to leeches and other lowering remedies, I have further to add to the remarks I have already made
nothing when discussing
these matters under the head of iritis.
Wecker and many other surgeons the
advantages
and more
to
are
be derived from the
especially
the artificial
M.
praises oemployment of leeches,
loud in their
leech, in
cases
of acute iuflam-
167
mation of the ciliary
body, and doubtless they are of use in instanpatient is a full-blooded and over-fed individual; but, as a general rule, people from this class do not form the majority of our patients suffering from irido-choroiditis ; on the other hand, it is from among the syphilitic, malarious-stricken, or poorly fed, and diseased portion of the people, that most of our cases come, and under these circumstances blood-letting, either local or general, is decidedly counter-indicated. Iridectomy should be resorted to in cases of irido-choroiditis, whenever the tension of the eyeball is much increased, and the disease has assumed an acute form, more particularly if the iris be also affected. The superior one-fourth of the iris should be removed. If this operation is resorted to sufficiently early, the majority of eyes affected with even this formidable disease may be saved, and no other plan of treatment that I am aware of is to be relied on with anything like equal certainty. It too often happens, however, that palliative measures are first attempted, and valuable time is lost in leeching, and the like systems of treatment; the inflammatory action spreads to the choroid or retina, and iridectomy is then comparatively useless; it may prevent general inflammation and abscessof the eyeball, but is not likely to act beneficially upon the patient^ sight. A promptly executed and icell performed iridectomy is the only plan of treatment tve can rely upon ivith any confidence in cases of acute ces
where the
Instances of sub-acute inflammation of the
irido-choroiditis.
ciliary body, depending on sympathetic irritation propagated from the other eyeball, when undergoing atrophy, or such like changes, must be overcome by removing the source of the irritation. As a general rule, it is advisable, underthese circumstances, to extirpate the diseased globe, rather than to remove its anterior section, allowing the contents of the eyeball to escape, because in the stump thus left may be situated the source An exception to of all the mischief going on in the other eye. this rule is to be made in cases where the irritation originates from
foreign body,
a
or
some
part of the diseased globe remove
of the entire
the
source
globe ; in eyeball.
;
such cause situated in the anterior may then possibly be able to
we
of the disease
this
case
by excising
the anterior part taking away the
it is of course useless
consulted by a patient, one of whose eyes has other destructive changes, and symptoms otherwise not to be accounted for, of haziness of vision, and in fact of sub-acute inflammation of the ciliary body in the sound there can be no doubt that eye have made themselves manifest, sympathetic irritation is the cause of these changes, and the line of practice indicated is plain enough ; extirpation of the 'diseased globe is the only chance of saving the best eye. If therefore
we are
undergone atrophy
or
LECTUEES ON DISEASES OP THE IEIS.?BY DE. C. MACNAMAEA.
18G7.]
that already prescribed in other forms of inflammation of the iris ; but we frequently meet with complications in instances of this description, arising from the lens having been injured, together with the iris. Under these circumstances the capsulo
ORIGINAL COMMUNICATIONS/
is often
LECTURES ON DISEASES OF THE IRIS.?No. IV. Bx C. Macnamara, Superintendent of the Calcutta Eye Infirmary.
but it becomes necessary to resort to iridectomy, otherwise the communication between the chambers of the eye
being occluded, an accumulation of fluid takes place in the posterior and vitreous chambers of the eye, which is certain in time to produce destructive changes in the retina. In these cases of closed pupil, the iris often bulges forwards towards the cornea from the pressure of the aqueous fluid behind it, but its pupillary border, being bound down to the lens, cannot be thrust forward in this way, and appears as it were in a pit(funnel-sha ped). Numerous proceedings have been advocated for the relief of this state of things, among which operations for the formation of an artificial pupil hold a prominent place, but it may safely be affirmed that an iridectomy made behind the upper section of the
cornea
is the correct line of treatment to
be pur-
exceptional cases, where the cornea is opaque m this situation. Iridectomy embraces all the advantages of an artificial pupil, and, in addition, has many valuable properties Of its own, not the least of which is, that it tends greatly unless in
to lessen the chances of recurrent iritis. It may therefore be affirmed that in instances of synechia, or closed pupil, which cannot be broken through by the aid of mydriatics or
safely the
operation of corelysis,
we
must resort to
iridectomy,
ex-
about one-fourth of the upper section of the iris. In this class of cases, the sooner the operation is performed the better : it is by no means necessary to wait till pain and irrita-
cising
tion in the eye have subsided, for in fact these symptoms are probably kept up by the synechia, and, if we wait till the inflammation has entirely passed away, the chances are that the integ-
rity of the deeper
tissues of the eye will have been
destroyed
in
the meantime. The amount of sight that the patient may possess
ought not to influence us as to the necessity of iridectomy; the central portion of the pupil may be clear, and yet no communication may exist between the chambers of the eye, and under these circumstances, although the patient may see tolerably well, we
perform iridectomy ;'on the other hand, perception of light, it is almost useless operating with an idea of improving the sight, for it is more than probable that detachment, or other destructive changes in the retina, which iridectomy cannot possibly influence, will have taken place. In cases where the iris bulges prominently forwards towards the cornea, indicating the collection of a considerable quantity of fluid in the posterior chamber, iridectomy is les3 likely to be successful than if the iris is in its normal position ; must not hesitate to if the patient has no
are still further reduced if we can make out a central opacity in the capsule of the lens,*a condition indicative of detachment of the retina. There may be some little difficulty in removing a portion of the iris in cases where it is swollen, from the pressure of
these chances
the
products
of
inflammation,
or
has
undergono atrophy.
Under
these circumstances, Yon Graefe remarks : "I employ straight pu-
pillary forceps with sharp teeth," which, instead of following ordinary direction, I apply to the iris somewhat perpendicularly. According to my experience, such an instrument is of very great service under these circumstances." (Page 284, Graefe on Iridectomy, New Sydenham Society, 1859. The general principles upon which we should conduct the treatment of a case of traumatic iritis, differs in no respect from the
and
the lens substance
swells, becomes
presents
corelysis,
sued,
perforated,
the iris, keeps up violent irritaopaque, and, by pressing upon tion and inflammation of the part. Whenever a case of this itself to our notice, it is well to remove the lens kind
As I before remarked, in cases when the pupil is entirely closed by false membranes, or its margin is wholly bound clown to the lens by synechia, we cannot perform the operation
of
165
at once ; the patient should be placed under the influence of chloroform, and a Weiss's stop-speculum having been adjusted, the surgeon should make an opening through the upper portion of the sclerotic as if for iridectomy ; about a fourth of the iris be removed should be excised,' and the lens must then and there X either by a scoop, or, if very soft, by means of a Bowman's suction instrument ; a few drops of a strong solution of atropine
dropped into the eye, and the case treated as one of ordinary linear extraction. The success of this operation depends upon the promptness with which it is undertaken ; if the surgeon attempts palliatives, such as leeches and the like remedies, in the hope of reducing the inflammation, the chances are, that his opportunity will slip away, and general inflammation and, it may be, abscess of the globe will supervene; whereas if iridectomy is at once performed and the lens removed, the patient will be saved much suffering, and with the aid of a lens will probably regain a very fair amount of vision. Occasionally a chip of steel, or some such foreign body gets lodged in the iris, causing violent inflammation ; if the lens has not been wounded, we may succeed in extracting a foreign body of this kind with a pair of canula forceps, or I do not hesitate to make a free opening in the cornea, and introduce a pair of iridectomy, or small forceps of the kind, and securing the offending body, remove it from the eye. Should the lens have been also involved, it is advisable to perform an iridectomy, including the foreign body, in the portion of the iris excised, and then "are to be
t
extract the lens as above described. I have already stated that degenerative
changes in one eyeball may, by sympathetic irritation, affect the other eye, causing an insidious form of iritis, or irido-clioroiditis, which generally advances steadily, ending in total blindness, unless wo can remove the source of irritation, that is, the primarily
diseased
eyeball. Ibido-choeoiditis.
Irido-clioroiditis, often described as cycilitis or inflammation of the ciliary body.?It is evident from the anatomy of the parts that iritis must be very apt to extend to the ciliary body ; in fact wo can hardly conceive a case of severe inflammation of the iris existing, without the ciliary processes becoming more I shall not, however, dwell or less involved in the disease. of in cases of the kind, form this irido-clioroiditis, because, upon we shall have distinct indications of the existence of iritis, aud. if acquainted with the more prominent symptoms of inflammation of the ciliary body, the diagnosis of the case can present I shall confine my remarks, therefore, to the no difficulty. features of inflammation of the ciliary more characteristic body, contenting myself with observing, that as disease going on in the iris is likelj to spread backwards, so inflammation commencing in the ciliary body, will often extend both to the iris and the choroid. In mild cases of iritis we are sometimes perplexed as to the very great impairment of vision from which our patient suffers, the state of the iris, aqueous, and cornea, being insufficient to
account for the symptoms. Under the circumstances, our suspicions should be aroused as to the existence of complications in the ciliary body, inducing opacity of the retina and haziness of of sight, the visual the lens. If, in addition to the
impairment contracted, and there is pain on pressure over region of the ciliary body, we may be almost certain that field is also
the we
THE INDIAN MEDICAL GAZETTE.
100 have to deal with
most
a
insidious,
but
Irido-choroiditis may be
destructive,
form of
conveniently
described under three
serous, and parenchymatous, or suppurative form of the disease. In plastic irido-choroiditis the patient complains of pain in the made over the region of the eye, increased on pressure being bo.lv, and in some instances he suffers from intense ciliary
heads?the
plastic,
ciliary
neurosis. In severe cases there is always more or less intolerance of light. The pupil responds but slowly, if at all, to the stimulus of light, and even strong mydriatics may fail to dilate it, in consedone to the
long ciliary nerves in their ciliary body. In acute cases there or less conjunctival congestion, and a zone of injected sclerotical vessels surrounding the cornea, but in milder instances this symptom may be almost wanting, specially if quence of the
injury
passage through is always more
the
case
be
a
and iris have
the inflamed
chronic one, and the circulation of the choroid adapted themselves to the altered condition of the
The fibrous structure of the iris and the cornea
parts.
are
yet the" patient complains of dimness of vision, the impairment of sight increasing after sunset, or in a dim light. On examining the eye with the ophthalmoscope, we shall find its fundus occluded by a cloudy condition of the vitreous humour ; this state of things of course acoften
perfectly healthy,
and
counts for the haziness of the field of vision from which the If the dissase is allowed to advance unchecked,
patient suffers. further changes
go on in the vitreous humour ; it becomes fluid' and small flocculent bodies may be seen moving in it; whenever the individual turns his eye from one side to the other, these
give rise to very distressing symptoms ; the instant the fixes his eye on an object, they fall forwards and obstruct the sight to a greater or less extent, and they are constantly whirling about before the patient's eyes. The field of vision subsequently contracts, detachment of the retina having flocculte
patient
occurred, and ultimately the patient's sight is entirely-destroyed.
pathological changes which produce these changes are^ ciliary body to those described as pathagnomic of plastic iritis; the vessels and fibrous structure of tho part become atrophied and destroyed, from organized plastic formations, and as these changes advance, the nutrition of the vitreous humour is impaired ; it degenerates, becomes first hazy, then fluid, and detachment of the retina results either from this cause, or from an extension of the disease to the choroid, and from serous effusion taking place between it and the retina. Serous irido-choroiditis is usually a most insidious form of disease, by no means of uncommon occurrence among ill-nourished and malarious-stricken individuals, such as many of the lower classes in all parts of the world must necessarily be; and consequently we have always cases of the kind attending the outpatient practice of the Calcutta Ophthalmic Hospital. In the early stages of serous irido-choroiditis, probably the only symptom from which the patient complains is dimness of vision ; everything appears as though seen through a mist, and these symptoms are more marked in a dim light, as for instance after The
similar in the
sunset: in fact so prominent a featuro is this of the disease, that instances of the kind are mistaken for night blindness. As the disease advances, the patient complains of opaque bodies floating about before his eves; these symptoms, as'above-mentioned, of tho vitreous hudepend on haziness, and subsequent
fluidity
There may be little or no pain in the eye, and the sclerotic zone of congested vessels may be entirely wanting. The pupil and responds but slowly, if at all, to tho stimulus of
mour.
frequently
takes a
considerable time to act,
light,
even under the influence of strong mydriatics. In other cases the serous effusion takes place rapidly, and under these circumstances tho intraand tension of the eyeball being occular
pressure,
suddenly
augmented, the patient experiences very great pain in the eye and .corresponding side of the head, the sight for tho time being
1867,
completely destroyed. In these acute cases, the poslayer of the cornea becomes hazy, its epithelium degenerating into opaque flocculent-looking masses, giving the cornea a speckled appearance, which is often so dense that the fibrous structure of the iris cannot even bo seen through it. Parenchymatous iriclo-choroiclitis is a most destru ctive form of disease, too often terminating in suppuration, in which case the pus formed in the ciliary body is apt to burst through and appear as an hypop ion in the anterior chamber. The symptoms induced by this disease are necessarily more acute than in either the plastic or serous forms of inflammation of the ciliary body. The patient complains of violent pain in the eye, extending to the temple and side of the face, and of almost complete loss of sight; great intolerance of light, and epiphora. The conjunctiva is deeply injected, and chemosis often exists ; the eyelids are not uncommonly puffy and swollen. The zone of sclerotic vessels is always present, depending as it does on the impeded state of the circulation going on in the ciliary body, but the injected chemosed sclerotic may be hidden by the inflamed and conjunctiva. Unless the disease be arrested in its early stage, the inflammation passes on to suppuration, and the pus bursts through the iris, and sinks down into the lower part of the anterior chamber. The sudden appearance of an liypopion, which, from the appearance of the parts, does not depend upon ulceration of the cornea, or suppuration of the iris, should at once lead us to suspect the existence of parenchymatous iridoehoroiditis. In these cases of suppurative cycilitis, it is evidently useless attempting to dilate the pupil, the functions of the nerves of the iris being in all probability destroyed for the time by the changes going on in the ciliary body. If the vitreous humour can be seen, it will be found hazy, and probably flakes of lymph will be noticed floating about in it. As the disease advances, in verymany cases, the sclerotic covering the region of the ciliary body undergoes degenerative changes ; it becomes thin and yields to the intra-occular pressure, and a staphyloma of some extent forms, often well nigh surrounding the eyeball, and occupying the region of the ciliary body. By degrees the choroid, and in fact all the tissues enclosed within the sclerotic become involved, and the disease but too frequently terminates either in atrophy, or, in the most acute cases, in abscess of the globe of the eye. The causes which give rise to irido-choroiditis are as numerous as those which induce iritis; syphilis, malaria, rheumatism, and the like affections are some of the more immediate influences which originate this disease ; in fact it so almost
terior
inflammation of the ciliary body.
[July 1,
?
often occurs as a sequence of iritis and vice versa, that the influence which excites the one form of local disturbance, is well nigh sure to induce the other. We sometimes see iridcchoroiditis
resulting from operations, or other injuries to the eye involving the ciliary body, and a most insidious and dangerous form of inflammation may without doubt occur in the ciliary body from sympathetic irritation propagated from the other eye, Unwhen undergoing atrophy or other degenerative changes. der these circumstances, the abnormal action in the ciliary body follows a very insidious course ; the patient frequently complains of little or no pain in the affected eye, but of gradually increasing dimness of vision, -which cannot be accounted for except from the presence of the other diseased eyeball, but on examining the best eye, wo shall at once discover the nature of the mischief going on ; the vitreous humour will appear hazy, and very probably opaque patches will be' seen floating about in it; these changes arising from sympathetic irritation propagated from the other eye, and affecting fhe circulation in the ciliary body and choroid, and consequently the nutrition of the vitreou3 humour under examination.
Treatment.?In considering the treatment to be adopted in cases of irido-choroiditis, we must evidently carefully examine all the circumstances of the case ; if arising from constitutional abnormalities, a different lino of treatment must be
July 1,
LECTURES OjST DISEASES OF THE IRIS.?BY DR. C. MACNAMARA.
1SG7.]
ployed to that which is necessary, if the disease arises from local or sympathetic irritation. In many instances of plastic and parenchymatous irido-choroiditis, we shall be able to trace the disease back to the effects of primary or inherited syphilis, -and
in
cases
of this kind
we
in iritis
must resort to mercury
as
recommended
arising from this cause. The mercurial vapour baths are particularly useful in these cases, not only on account of the specific action which the drug appears to exercise over syphilis. but also by means of the profuse perspiration the bath causes, and' which is frequently most beneficial in acute disease. In other cases of inflammation of the ciliary body depending on miasmatic influences, quinine must be administered; this is doubtless
a
very indefinite rule?for how
aro we
to
ascertain if
patient is suffering from the effects of malaria ? With regard to India, I doubt if every resident in the country, European or Native, is not tainted by the pernicious influence of miasma ; some of us appear, like the inhabitants of the Nepaul Terai, to become comparatively inured to the subtle poison, others resist it by the natural vigour of their vital powers, but among by far the majority of Europeans and Natives in India it may be slow, but deleterious changes are effected in the organism by malaria, consequently local inflammations, such as these we are now considering, may reasonably be surmised to be caused by miasmatic influences, if we fail to detect any other probable cause for the disease. Quinine, under these circumstances, should be employed ; it can seldom do any harm unless given in over-doses, and we may generally judge from its effects if it has any beneficial action on the disease, after using it for three or four days. As a general rule, five grains of quinine, three of sulphate of iron, and ten drops of diluted sulphuric acid may be given three times a day. In cases of neuralgia of the supra-orbital nerve, there is generally considerable hypersemia of the choroid and retina, and it may be a matter of some uncertainty whether the pain from which the patient is suffering arises from congestion of the tunics of the eye. or from simple neuralgia ; if from the latter, there is almost sure to be tender, a
pressure over the spinous processes of the first two cervi.' cal vertebra?; pressure exerted in this situation also often brings if affected with on a shooting pain in the supra-orbital nerve, ness
on
of the choroid,
by
pressure
increase of
no
symptoms arise from congestion pain in the parts would be induced
should the
neuralgia, whereas, applied
over
the vertebra;.
As I have before remarked, we are often consulted by patients suffering from a sub-acute form of serous irido-choroiditis, the chief and perhaps only complaint they have to make being indimness of vision, most marked after sunset ; the pupil
creasing sluwishly,
acts
but in other respects the eye may appear toler. we examine it with the ophthalmoscope, and
ablv healthv, until
humour. The majority of then discover opacity of the vitreous and the mercurial vapour cases are of syphilitic origin, a mixture conbath should be employed, but I also administer of mercury and taining the twelfth of a grain of bichloride in water three times a day; five of iodine of we
these
potash,
grains drugs
have to be continued for some time, but their beneficial action on the disease is often very marked indeed. Counin the form of a succession of blisters, or an issue these
ter-irritation in opened in the skin of the temples, are invaluable adjuncts the treatments of all forms of sub-acute irido-choroiditis. In acute cases,
opium
is
a
remedy
which we can never
safely
dis-
pense with ; it must be given in full and repeated doses, so as to ensure the patient's rest, and comparative freedom from pain. With regard to leeches and other lowering remedies, I have further to add to the remarks I have already made
nothing when discussing
these matters under the head of iritis.
Wecker and many other surgeons the
advantages
and more
to
are
be derived from the
especially
the artificial
M.
praises oemployment of leeches,
loud in their
leech, in
cases
of acute iuflam-
167
mation of the ciliary
body, and doubtless they are of use in instanpatient is a full-blooded and over-fed individual; but, as a general rule, people from this class do not form the majority of our patients suffering from irido-choroiditis ; on the other hand, it is from among the syphilitic, malarious-stricken, or poorly fed, and diseased portion of the people, that most of our cases come, and under these circumstances blood-letting, either local or general, is decidedly counter-indicated. Iridectomy should be resorted to in cases of irido-choroiditis, whenever the tension of the eyeball is much increased, and the disease has assumed an acute form, more particularly if the iris be also affected. The superior one-fourth of the iris should be removed. If this operation is resorted to sufficiently early, the majority of eyes affected with even this formidable disease may be saved, and no other plan of treatment that I am aware of is to be relied on with anything like equal certainty. It too often happens, however, that palliative measures are first attempted, and valuable time is lost in leeching, and the like systems of treatment; the inflammatory action spreads to the choroid or retina, and iridectomy is then comparatively useless; it may prevent general inflammation and abscessof the eyeball, but is not likely to act beneficially upon the patient^ sight. A promptly executed and icell performed iridectomy is the only plan of treatment tve can rely upon ivith any confidence in cases of acute ces
where the
Instances of sub-acute inflammation of the
irido-choroiditis.
ciliary body, depending on sympathetic irritation propagated from the other eyeball, when undergoing atrophy, or such like changes, must be overcome by removing the source of the irritation. As a general rule, it is advisable, underthese circumstances, to extirpate the diseased globe, rather than to remove its anterior section, allowing the contents of the eyeball to escape, because in the stump thus left may be situated the source An exception to of all the mischief going on in the other eye. this rule is to be made in cases where the irritation originates from
foreign body,
a
or
some
part of the diseased globe remove
of the entire
the
source
globe ; in eyeball.
;
such cause situated in the anterior may then possibly be able to
we
of the disease
this
case
by excising
the anterior part taking away the
it is of course useless
consulted by a patient, one of whose eyes has other destructive changes, and symptoms otherwise not to be accounted for, of haziness of vision, and in fact of sub-acute inflammation of the ciliary body in the sound there can be no doubt that eye have made themselves manifest, sympathetic irritation is the cause of these changes, and the line of practice indicated is plain enough ; extirpation of the 'diseased globe is the only chance of saving the best eye. If therefore
we are
undergone atrophy
or
