notes

treatment of some COMMON OCULAR AFFECTIONS.* on

the

BY

E. R.

Chambers, F.R.C.S., D.O.M.S.,

Surgeon, Eye Hospital,

and

Ophthalmic Surgeon,

Royal Infirmary,

Bristol.

^ this short paper, which is rather ^vant to bring to your notice ^th common ocular diseases.

V

Conjunctivitis.?If

we

this condition,

find it is

we

I

few facts connected

consider the

burning

that

a

disjointed,

always

pain caused a gritty or

of

type, and very often the patient is convinced he has a foreign body in his eye, as this may

Produce

exactly similar symptoms. The character of the great importance from a differential diagnosis

Pam is of

Point of view, as it at as iritis and subacute

once

excludes such conditions

glaucoma. The inflammation, injection, typical, the blood vessels eiiig brick red, tortuous, and moving with the Coiljunctiva because they are in it. They are largest at their origin, which is at the periphery of the eye, and gradually diminish in size as they near the corneal ^argin. There is always a discharge in conjunctivitis, ?r

vascular

is also

ut in mild cases this is not obvious : its presence Caft often be ascertained the lower lid, by everting

letting the sac fill with tears, when lscharge will be seen floating in the clear

beads of

tears,

or

Medico-Chirurgical Society

on

*

Communicated 'April, 1932.

V?L- xlix.

No.

to

184.

the

Bristol

Mr. E. R. Chambers

132

patient may state that his lids are slightly stuck together when he wakes in the morning. Now, as regards treatment, lotions and drops

the

all very well, but I am convinced that in order to cut an attack short there is no better treatment than painting the lids the case is are

immediately only efficient means for a diagnosed, One case that lias persisted in spite of treatment. as cent, is mercurochrome as per good anythingUse a fine probe with a very little cotton wool, anaesthetise the eye with a drop of four per cent, cocaine, and in dealing with the upper lid do not evert it, but tell the patient to look down, catch hold of the lashes, and raise it from the eyeball, and then slip the probe under : by this method the painting is carried right to the top of the fornix, and so applieC^ to the whole of the conjunctiva, whereas if the lid is everted and then painted the fornix is not touched. Many cases of conjunctivitis will persist in sprte and it is the

of treatment, unless this includes nasal antisepticsThere need not necessarily be a history of nasal

spreads to the eye via tlie nasal duct, and although antiseptics applied to the eye run down the duct into the nose, they are' apparently, not sufficient to deal with the infectionIritis.?The pain in this condition is very typica^ and quite different from that of conjunctivitis, -p is not in the eye itself, but in the bones of the orb^ and face, and is of a neuralgic character. The vascular congestion is typical: it consists of straight, hair-like The infection

catarrh.

vessels of

a

lilac colour situated beneath the

conj

junctiva, and having their maximum intensity aroun the corneal margin. In iritis there is no discharge* but

an

increase

in

considerable aid in the

clear

and

diagnosis

normal

tears,

of iritis is to

compare

Treatment

of

the irides of the

133

Common Ocular Affections

two eyes

:

the affected

one

will show

a

contracted pupil, and change in its normal colour, arid the marking on its surface will be obscured by

^dema. The vision is always considerably reduced ^ iritis. In

investigating

every

Septic focus.

As

investigation

made

the

be

^sponsible, mouth,

and

and

examination,

ahvays

be

^ftle,

as

as

any

complete pathological we

have found

and

prostate regards the teeth, there is abscess

apical

it

only

can

exclude

to

many years, nasal sinuses,

the

that

iritis

primary

a

made

over

accessory responsible. As

doubt

of

cause

result of

a

teeth,

Mainly

110

the

endeavour should

the

most

in the well-cared-for

occurs

be

is

recognized by

it is often missed.

The

an

X-ray

prostate should

with recurrent iritis in the young have conclusively proved that the

suspected we

??nococcus

can

lie dormant there for many years.

Since complete pathological investigations are niade in cases of iritis, it is interesting to note "

now

that

"

so-called rheumatic iritis is far less common than in former years. I will not trouble you with the treatment of iritis, ^ hich is well known, but there are one or two points ?rth For instance, sodium salicylate

Is

e

?r

emphasizing. drug to give internally, but it given in large doses. Heat, applied in some

by

far the best

other

thin,

The to the eye, should never be omitted. a shade wool worn under of cotton pad

be

discarded, and

extending

well

a

beyond

piece of gamgee the orbit is the only

thick

llleans of keeping the eye well protected and eVen

form

small

should issue

must

at

an

temperature. Squint.?I will deal with the non-paralytic or c?Hcomitant variety. A squint occurring in a child

Mr. E. R. Chambers

134

up to twelve months of age is of little importance unless it is considerable and fixed permanently 111 A child up to this age has acquired very little power of fixation, and in many cases, as this develops, the squint will disappear. After twelve one

eye.

squint should receive definite attention? it is not likely to recover spontaneously, and will

months as

a

probably get

worse.

To be able to undertake the treatment of it is necessary

realize that

to

intelligently endeavouring (1) to prevent from becoming blind from disuse, and train the faculty of fusion

the and

squi*1^ we

are

squinting eye (2) so to educate child uses

that the

both eyes, fuses the two retinal images, and thus has binocular vision. Now, in order to prevent the

eye from becoming blind it must be brought into use, and this can only be done by excluding or some of the vision from the straight eye. The

squinting

most efficient way to carry this out is to

straight eye altogether by strapping probably the best treatment if

a

exclude the over

pad

the child is i10^ too young, and if it possesses useful vision in the squinting eye. It is, however, impossible to carry this out in young children, as they will not keep the This is

pad on, and they cannot most

some

from

remove

useful

in

adopted which lS Atropine eye. it paralyses the

method has to be

these

the

cases,

as

accommodation, and so, at any rate for near puts the eye out of action. An instillation of cent,

solution

Whether is

atropine

adopted,

a

week

or some

is

other method of

original squinting

as

1

Per

eye

occlusi?JJ

prolong^ becomes straight

squint appears in the other.

advantage,

a

usually suffici611^

it will often be found that after

treatment the

and the

once

objects?

This

it is definite evidence that the

is cTl*

treatniei1

Treatment

Common Ocular Affections

of

135

has achieved

the required results, and that each eye has almost certainly good vision. In this way a

Scluint may be made to alternate between the two eyes until the child is old enough for something more be done. Never put atropine into both eyes at time.

same

As you know,

squinting children practically always have some error of refraction, and it is of the greatest ^iportance that this should be investigated. One is

?ften asked ^0r and, if

at what age

child should be examined

a

I would necessary, fitted with glasses. Sllggest that there is little harm in waiting until the of two years, if in the meantime the atropine

treatment

attempt

I know that

is carried out.

to make

a

111

the cradle, but Parts of the world.

child

glasses

wear

perhaps

some

oculists

whilst it is still

babies differ in different

Glasses having been prescribed, it is of the greatest

Alportance

Mothers

that

should

they

be

worn

constantly.

this, object squint will not llriprove if the parents are allowed to have their ^ay. ]^ror (jQes the treatment of squint cease with

the

often

Gaining. ai1

The child may still be in one eye, and the fusion faculty need In young children atropine may still have

prescribing

ai*blyopic

of

glasses.

be instilled into the straight eye, or in older children' occlusion disc worn over this eye to encourage

squinting

^?re

Jfain aily ?r

but the

to

eye to

work.

As the child becomes

intelligent every endeavour must be made to the fusion faculty. This is best carried out by exercises with some form of stereoscope; five

ten minutes

a

day

is

quite

sufficient

for

young and the child need not become bored with 0rie set of pictures, as there are now so many different

children,

Varieties

made

specially

for this purpose of fusion

136

Mr, E. R. Chambers It is

training. of

squinting

interesting

children

to note that

has

been

as

better

the training

understood,

adequately carried out, the numbers requiring operation have greatly diminished. Foreign Bodies in the Eye.?These are most commonly found on the surface of the cornea and and

so

more

If you find a foreign body in the cornea never fail to evert the ^ upper lid, and look for one in this position also ;

on

the

conjunctiva of the upper lid.

found, and you will derive no credit for the removal of the obvious one if you leave the In removing a foreign body from the cornea other. and insert the use a under it will often be

sharp spud,

point just

and lift it out, your object of the epithelium as possible,

to

being as

preventing necessarily scrape the removal of

antiseptic

a

spuds must epithelium. After

Blunt

off much of the

foreign body

from the

should be inserted into the

sac, and this should its oily nature allays

little

as

this is the chief barrier

corneal infection.

in

remove

preferably pain. We

cornea

sonie

conjunctival

ointment, aS of use an ointment per cent, iodoform*

be

an

1 per cent, mercurochrome or 1 The eye, having been anaesthetized with cocaine, f?r the removal of the

dust, etc., for in order to let to

should

always

be

remains insensitive als? this for time; reason, and

foreign body,

some

the

epithelium regenerate,

worn over

the eye for

a

pa^

twenty-f?lir

hours.

Blepharitis.?This consists of an infection, usually the staphylococcal in origin, and of the glands at lid margin, and later of the hair follicles themselves* olie Although a very common ocular condition, it is of the most neglected, yet it may often lead to i*1110 discomfort

in

after

years. Those very sensitive to such irritants as

eyes

which

are

wind, dust, si*11'

Treatment

?tc.,

often

owe

Common Ocular Affections

of

their trouble to

also such conditions corneal

consequent same

neglected blepharitis ; ingrowing eyelashes, with

as

irritation, Recurrent

condition.

137

a

be ascribed to the

can

mild

attacks

of

con-

junctivitis will often rapidly disappear if the infection ?f the lid margin is dealt with. The object aimed at in the treatment of blepharitis

18

to clear the

infection,

not from the surface of the

lid margin, but from the

This

can

often be

efficiently

glands

and

carried out

gland

by

ducts.

the so-called

Method of milking the lid glands. After cocainizing the conjunctiva, the edges of the lids are held with the thumb and forefinger, and squeezed with a Movement towards their

the effect of this

treatment

a

is often

edges : surprising in

which has

case

Withstood other methods of treatment, and it should be more In one often

generally adopted.

blepharitis

finds that some antiseptic ointment has been prescribed,

^rith instructions that it be smeared over the edges ?f the lids. This is often useless, as thick and hard

scabs have formed, so that the ointment never reaches t^e lid margins. The scabs must therefore be first

removed, s?

and this must be

that the

as, if it

done with

underlying granulation

great care, injured,

tissue is not

is, fibrous thickening of the lid margins may result, with the formation of entropion or ectropion. The best way to remove these scabs, and this should

always be done before any ointment is applied, is to s?ak the lid margins gently with a warm solution sodium bicarbonate, which is

Avool swabs.

In the

case

of children

applied

with

with cotton

blepharitis

never

fail to exclude the presence of infected tonsils and

adenoids

;

it is

after the

how many cases will clear and throat have been attended to.

surprising

nose

138

Treatment

Blepharitis rarely

of

Common Ocular Affections

occurs

in

healthy child, and every improve the general violet light baths are of a

endeavour should be made to condition. but

General ultra

value, and

definite sea

a

change

to

air often does these

country air is beneficial, cases

good, unless protecting glasses Autogenous vaccine treatment

are

and in

severe

cases

more

harm than

worn.

is very valuable, the vaccine should be injected

skin, close to the lid margin. In conclusion, just a few words about atropine.

under the

indiscriminately, but only when you are certain of your diagnosis. Remember that it is the most powerful pupil dilator we possess, and its action cannot be counteracted by any other drug, if there is any doubt, use homatropine, which can be counteracted with eserine. Atropine is a severe irritant to the conjunctiva if used over long periods, and acute glaucoma induced by atropine is far from being unknown.

Never

use

it

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