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