BERKELEY LIBRARY UNIVCaSITY OP CALlK)tNIA DISEASES OF THE EYE AND HOW RECOGNIZED A Series of Articles on the More Common Diseases with which the Optician Meets in His Every-Day Work— The Causes, Symp- toms, Diagnosis and Outlines of Treatment BY C. W. TALBOT, M. D. NEW YORK FREDERICK BOGER PUBLISHING CO. ONE MAIDEN LANE COPVRICHT lyiu BY Freukkick Bogkk Pui;. Co I MaidI'N Lank, New York. Press of Tin; Oi'iuAi. Ioii<« Diseases of the Eye and How Recognized Part I. — Diseases of tiik Eye-lids'. The optometrist should cuUivate the habit of ob- servation in every case of refraction he has to deal with. Not only for the patient's benefit and incident- ally the raising- of one's self in the estimation of the l)atient, but because so much can be learned of the condition by simple inspection. You can tell whether or not the condition is a normal one or an abnormal one, and the early diagnosis of any eye disease, will if promptly treated, insure more speedy and complete cure which reflects on the optometrical profession and raises it in the eyes of the public. There can be no fixed rule for conducting an exam- ination of the eye, since in many cases to follow a routine method would not only be a waste of the op- tician's time but the patient's as well, so that it is im- possible to go through some routine procedure in ev- ery ocular examination. In the majority of cases it will be found far safer to make just as tJiorough ex- amination as the time im'll permit. The things to be noticed by simple inspection, are the eyes red or inflamed? are the margins of the lids ^S2B ■I DISEASES OF THE EYE red? arc the lashes stuck together — several in a clump? are the lids stuck together? is there any excessive flow of tears? any signs of a stye? any lump or "kernels" in the lid? is the cornea clear or hazy and are there any spots on it? do the lashes rub the eyeball? do the lids turn out or drooj)? is there any growth upon the eyeball ? All these, and more, are common symptoms to look for and if present can be readily seen by sim- ple inspection, just ordinary observation. We will first consider the external diseases of the lids, and the first will be inflammations, blepbaritis as it is called. The most common form is ])lcpliaritis marginalis (marginal inflammation of the lid) or tinea tarsi as it is sometimes called; a very chronic and trouble- some affection. Ihis disease has as its distinguishing features the red and inflamed edges, with more or less gluing to- gether of the lashes, two or more in a clump with crusts of the dried secretion forming on the skin around the lashes. If of long standing as the most of them are, we will see a shining red surface underneath when the crusts are peeled off which may take with them a dead lash or two. See figure i. This condition exists with other inflammatory trou- l)lcs or alone, and is found in all classes of people, more frequently perhaps in that class of society in poor circumstances with the unsanitary surroundings or among the poorly nourished of the well-to-do. Eye- strain is always associated with it, which makes it im- possible to effect a complete cure or pennanent cure until the errors of refraction and the muscular anom- alies have been corrected. This disease does not as a rule cause any incon- venience, except for the ai)pearance of the eyes, which AND now RECOGNIZED. S most certainly do ndt add to one's attractiveness. Most patients have come to me more on account of the dis- figurement due to the reddened border of the hds, than for any distress they may have experienced. It occurs in both children and adults, more com- mon I have found in young adults, high school pu- pils. The disease may become quite severe in persons of lowered vitality, and under the crusts show a raw or Mai-ginalis. Eyclnslu' s Stl ick Ing.-l licr rusts on mnrgin of li (1 an long the las] bleeding surface \vith the formation of small ulcers along the edges of the lids. About the only subjective symptoms arc those burn- ing or smarting with a feeling of heat and irritation which is always aggravated by exposure to dust, wind or bright light; ordinarily, the patient does not com- plain, and as T say, would be fairly content if it were not for the disfiirurement. G DISKASES OF THE EYE This disease is troublesome, chronic and very per- sistent, and in untreated cases sooner or later results in a thickening of the Ids with a loss of the lashes which permits the entry of dust and foreign bodies with their consequent deleterious effects. If untreated for any length of time, this disease en- tails a series of sequelae, some of which to a certain extent react upon the disease itself and greatly aggra- vate it ; these are permanent loss of the lashes from II. — Stye or Hoicloliiini. ml sIkiws quite ;i •^wclliuu destruction of the hair follcles through infection and suppuration, this not only greatly disfigures but leaves the eye without its hairy defenders and renders it more liable to injuries from foreign bodies. There may be only a partial loss of the lashes and the re- maining ones may grow irregularly, scratching the eye- ball ; this is due to the formation of little scars forming at the site of the small ulcerations. In long standing AND HOW RECOGNIZED. 7 cases there is an inflammatory condition brought about with a more or less of a mucus discharge, this is known as catarrhal conjunctivitis which will be consid- ered later. Often times the full correction by glasses alone — especially if there is astigmatism — will effect a conv- pletc cure. ^ H Fig. III.— Chalazion or cyst of the Meibomian gland. Eye perfectly normal except for the growth or "swelling" in upper lid which pre- vents a wide opening of the lid. HORDOLEUM. Probably the next in frequency among the external diseases of the lid is the hordoleum or stye. This_ is of very common occurrence and a condition v^^ith which nearly every one is familiar. The duration of this painful and troublesome disease is, as a rule, quite short, only a few days for a single stye, but the afifec- tion is very aggravating on account of the pain which 8 l>ISi;.\SKS OF Tllli KYE is at times really quite severe, and the lids may be swollen almost shut. This painful disease is common in people who have had blepharitis marginalis and is due to an infection at the orot of the lash (in the hair follicle) and may truly be regarded as a boil of the lid. Early in the formation of a stye we notice as the first thing, the red lid, which is, however, distinguish- ed from the previous disease we have been discussing by the inflammation extended pretty well over the en- tire lid and not confined to the margins alone. Now if you will carefully run your finger lightly over the edge of the lid you will discover a swollen spot which is especially sensitive to the touch and in the center of which you Vv^ill find a lash. In a day or so the swell- ing at this point increases and the skin becomes tight and glistening and soon around the lash there appears a yellowish or creamy discoloration which sooner or later breaks and» allows i)us to escape. There is swelling of the entire lid (oedema) which shows a hard and painful nodule varying in size from a tiny red elevation to the size of a pea, the point of which is yellowish in color and if of several days du- ration, may, upon pressure discharge a drop of pus. See figure 2. The treatment depends largely on the character and age of the stye and uix)n the general condition of the patient, sometimes they are lanced and washed out witli a mild antisejitic solution, but the usual meth- od of treatment is with an ointment containing a mild mercurial salt. In the earliest stages of its forma- tion a stye may be absorbed by pulling out the lash in the center of the nodule, around which the stye is forming. Styes generally appear in "crops," that is, one after AND HOW RFXOONIZED. 9 another and when- they so occur it will be found that they are almost invariably aggravated hy refractive errors which they oftentimes accompany, and in per- sons subject to these repeated attacks, it is difficult to stop their formation without first correcting the re- fractive errors. Just how eye-strain acts as an etiological factor in the causation of certain lid diseases has never been satisfactorily explained, yet the consensus of opinion is that it is one of the prime and predisposing causes in the production of many of these diseases. Most au- thorities in this country and Europe are agreed as to the influence of eye-strain in creating certain lid as well as bulbar diseases and in the causation and per- petuation of many of the nervous disorders. They have arrived at th-s logical conclusion after the ob- servation of thousands of cases and are well supported in their views by an abundance of clinical data. CHALAZION. Next in order comes another lid affection which is also attributable to eye-strain, — the chalazion (Greek- meaning "hail"). A chalazion is a cyst of the lid, usually the upper one and is due to the closure of the openings of one of the little Meibomian glands, so that the secretion does not drain out but remains, increasing in quantity. This cyst is usually round and varies in size, as a rule about the size of a pea when first noticed, it grows slowly and causes no pain or inconvenience, ex- cept it prevents a wide opening of the lids when look- ing up. It is only slightly movable under the skin, see figure 3, but the skin is freely movable over it, and "s quite hard. The secretion forms so slowly that the patient is 10 DISEASES OF THE EYE unaware of the development of any swelling and it is never noticed until it reaches the size of a small pea, when the skin begins to bulge and they notice there is some interference with fully opening the lid, then they become aware of its presence. It is seldom seen in children, but is a disease chiefly confined to adults, or adolescents. The treatment is surgical and should be done early before the contents of the cyst have undergone any de- generative changes which renders it liable to break- through the inner surface of the lid. The operation is done under local anesthesia, is painless, and heal- ing usually complete in a few days without any deten- tion from one's vocation. ENTKOIMON, KCTKOl'ION, AND TRICHIASIS. Other lid troubles which the optometrist should be able to recognize and should refer to an oculist for treatment are, entropion, ectropion and trichiasis. Entropion is an inversion of the lid, a turning in of the edge of the lid so that the lashes rub on the eye- ball. This is usually the result of the trachoma (gran- ulated eye-lids) and is due to the formation of a cica- trix (scar) and its contraction; the old granulations in healing leave a scar which contracts as all scar tis- sue does and causes a drawing of the conjunctiva with a bending of the tarsal cartilage and the pulling of the lid in toward the eye-ball. See figure 4. This is a very serious condition and requires surgi- cal interference to restore the edge of the lid to its normal position ; nothing can be done to repair the damage already done to the cornea by the scratching, or to restore the delicate and velvety conjunctiva which has been replaced with the hard glazed scar tissue. ANn HOW RECOGNIZED. 11 This condition is also met with in people who have had the granulations treated with caustics, such as sil- ver nitrate, copper sulphate, etc., or from the result of burns by acids, lime, lye or other caustic agents, it is also seen in ckl people who have flabby lids with a spasmodic contraction of the orbicularis muscle which causes an inversion of the lid. In long standing cases the sclera is greatly inflamed, a beefy red ; there is profuse lachrymation and the cor- nea appears hazy, has a white and dead look due to the constant scratching of the lashes or hard scar tissue lining the lids, or both. This condition should be remedied as early as pos- sible so as to save what vision is left, before a dense white scar or leucoma forms over the cornea. The treatment is purely surgical. Ectropion is just the reverse of the above and is an eversion of the lid, a turning out of the edge of the lid, so that the conjunctiva is exposed. The sensitive lining of the hd becomes glazed and shining. See fig- ure 5. There are various causes assigned to the causation of this trouble, among which are, — paresis of the jtli nerve allowing the lower lid to droop through the paralysis of the orbicularis (paralytic ectropion) or it may follow a spasm of the same muscle due to some local irritation (spasmodic ectropion) or as is often the case it occurs in old people as the result of atro- phy of the orbicularis (senile ectropion) or it may occur as the result of burns, cuts and injuries to the lid which in healing leaves a scar which contracts antl pulls the lid away from the eye-ball (cicartricial ec- tropion). The treatment is as before, surgical; and should be done early, for obvious reasons. DISKASF.S or THE EYE I'iS. IV- — Entrojiion with trichiasis. The edge of tlie upi)er in so tliat the laslies scratch across the eye ball, giving it a wliite and ilead appearance. The entire conjunctiva is greatly inflamed, a regu lar network of vessels are seen extending over the sclera. Fig. v.— Ectropion of the lower, liil. Note the lurning oul of llic lid, exposing the sensitive lining to the air and dust. AND HOW RECOGNIZED. 13 Accompanying this trouble is the constant overflow of tears, more marked of course upon exposure to the wind or dust; the lower lid being turned away from the eye-ball, the tears do not drain into the tear duct but flow out over the cheek, which soon causes a roughness of the skin of the cheek and lid and re- sults in an "excoriation" or chapped condition of the skin. This overflow of tears is called "epiphora" and is also met with in other conditions, particularly that of closure of any part of the tear duct, which will be considered later on. Trichiasis is a term applied to an irregular curving of the lashes so that some of them rub on the ball, this is miscalled "wild hairs." It usually accompanies en- tropion but may occur with any inversion of the lid. The treatment of this troublesome condition depends largely on the character of the trouble and the cause ; sometimes where there are only a few lashes causing the trouble the offending ones are removed or de- stroyed by electrolysis or restored to their normal position by surgical interference. When there are two rows of lashes ; the ones along the inner edge of the lid may be small and white and grow irregularly, turning in against the sensitive eye- ball, this causes an inflammation of both the bulbar and palpebral conjunctiva, with an increased flow of tears and this condition is truly that of "wild hairs" or as it is called, "distichiasis," and the small and al- most invisible hairs must be removed or destroyed by the electric needle. 14 DISEASES OF THE EVE I SECOND SERIES. Part 1. — Exiernai. Diseases of the Eyehai.e AND Ln)S. \vn now notice the eve is more or less red. Your next query to answer is — why? The conjunctiva is sui)i)He(l with two sets of blood vessels, the anterior and the iwsterior, which is well to remember on account of their diagnostic value in determining the character of the inflammation. Scars or leucomrc of the cornea following old gran- ulated lids are often accompanied by an invasion of the cornea bv small blood vessels — pannus, as it Is called. In the more common inflammations of the eye, it becomes necessary to ascertain whether the deeper structures are involved ; to determine this, we notice whether or not the vessels move with a movement of the conjunctiva; this being loosely attached, can be readily moved; if the redness moves with it. .the in- flammation is one involving the superficial structures, while if the redness docs not move, the inflammation is one of deeper character and the deep vessels are in- volved ; both conditions frequently exist together. In deep seated inflammatirns the greatest zone of redness is immediately around the cornea-scleral junc- tion, as will be shown in iritis, whereas in the more superficial inflammations the greatest areas of red- ness are at the "retro-tarsal f )lds." Now, remember that the vessels which you see so prominent in an inflammed eye are so small as scarce- ly to be seen in a healthy eye. Pain is another factor which must be considered^ in the study of eye inflammations, and we can divide these diseases into two general classes; in the first, (a) the eye is wholly or partly inflamed without AND HOW RFXOGNIZED. 15 pain or discomfort; in the second, which can be sub- divided, there will be in the one more or less discom- fort without actual pain, whereas in the other (b) class the eye is distinctly discomfortable but very lit- FijT. \'I. — Everting the lower I'd, 16 DISEASES OF THE EYE tie or no pain, in the other (c) class the eye is quite painful. The first class (a) is seldom seen and rarely occur.; except in the case of sub-conjunctival hemorrhagic in the second class (b) there is discomfort, itching, burn ing and smarting with lachrymation and photophobia and more or less of a discharge, all of which may be present in a single case. It is diseases of this class that we consider in this paper. The posterior conjunctival vessels are prominent in the diseases we arc going to consider in this paper, they are the ones which are responsible for the red- ness. They become bright red with the engorgement of blood and move with the conjunctiva. The anterior ciliary vessels supply the sclera, iris and ciliary body and a congestion of these vessels gives the "zone of circumcorneal congestion" as seen in iritis, cyclitis, etc., and docs not move with the con- junctiva. Look closely — is there any "mucus" or any secre- tion? If so, is it clear, thin and semi-transparent and "stringy" or is it thick and of a yellowish color? Or is there an absence of any mucus or secretion, but just an excessive flow of tears? Foreign bodies in the eye — cinders, a lash or any of the more common forms of foreign bodies cause the stringy form of mucus, whereas true inflamiua- tory conditions brought about by micro-organisms gives rise to the thick and creamy secretion," or, as it is more correctly called, a "muco-purulent discharge." In cases where the foreign body has been in the eye only a short time and in iritis (and some other diseases), there is only the "profuse lachrymation." As foreign bodies are of such common occurrence we will first consider that point. First look for the offending particle on the eyebill. AND HOW RECOGNIZED. have the patient look up, down, toward the nose or toward the temple-^if it is not on the cornea it can Fig VII — First act of everting upper lid, the margin of the lid is grasped between the thumb and forefinger and ilulled down and away from the eyeball. 18 DISEASES OF THE EYE be wiped off with a tuft of cotton on a tooth pick, but if it is on the cornea it will be better to use a local anaesthetic, such as cocaine, alypin, beta-eucaine, etc , and you will refer your patient to some friend who is an oculist. And right here let nic say — don't send your patient but go with him, introduce him to the oculist, and all concerned will be better satisfied. The patient will feel that you are taking more than ordinary interest in him and will be far better satisfied ; will pay the oculist's bill with better grace, and for some reason or other seems to feel that you have his welfare at heart, and that you have confidence in the man to whom you are taking him. and it at once inspires his confidence in the oculist. Also reassure him that he will not be "robbed," and then take him to a man that you know, and know to be one who is not engaged in the practice of medi- cine solely for the money that's in it — just look around and you will find such a man, and take him to a man who is not so extremely pressed for time but what he can give the patient the attention due him, for careful eye work takes time ; you can't hurry, and the busy man must hurry unless he has an assistant or two. Remember this if you want a "square deal" for the patient and yourself. Again, many people have the idea, born either of hearsay or experience, that they will be "stuck." Now, the fee for removing a foreign body varies from nothing to ten dollars, and usually among some of the busier men the customary charge is $5. I have done it more times for nothing than I have for the five and find it pays. The onlv danger from a foreign h(^dv is the like- lihood of the formation of a corneal ulcer, and to quote AND HOW RECOGNIZEn. from a recent article of luiiie in one of tlic medical journals : "A small ami shallow nicer is (|nite common after Fig. VIII.— Iiisprctin.u the 11, .pn- li,l aft( 20 DISEASKS OF THE EVE the lodgement of a foreign body in the eye, especially in aged or debilitated persons; but in the young and robust, may cause little or no trouble, and may never be discovered — after a few days heal without any treatment whatsoever, the patient never having been aware of its presence. "The cause of so frequent ulceration of the cornea depends upon various influences, yct.thc most generally accepted etiological factor, i)erhaps, is the established fact of the frequent presence of bacteria in the con- junctiva which find a ready field for growth in an abraded cornea." So that it is a safe procedure to have the patient use a mild, soothing and antisejitic collyrium so as to eliminate the possibility of an ulcer forming; this is especially advisable if the body has lodged directly on the cornea or has been in the eye for a day or so. To find a foreign body it is usually necessary to "turn the lids." the upper one in particular. First look at the lower lid — to do this, place the tip of the finger near the margin of the lid and draw it down, tb.en push the finger backward (you can feel the lower rim of the socket as your finger goes over it) ; at the same time direct your patient to look up, "way up." at the ceiling just over their head. To get a look at the inner surface of the upi^cr lid is more difficult, but after practicing it a few times on yourself you will become quite adept. First direct the patient to look down and to keep look{ns[ doivn during the entire proceedino; (with the head tilted back about the way in Fig. VII.; the knees ■ off"er about the best place to direct them to look), now take your place behind and a little to the side and catch the edge of the lid (not the lashes) between your thumb and forefinger and pull it away from the evcball as shown in Fig. VIT. AND HOW RECOGNIZED. 21 At the same time you do this, some small blunt in- strument — a pencil, match or your finger tip, is placed at the upper edge of the tarsal cartilage and pressed downward ; at the same instant the lid is quickly turned over it. Now, by directing your patient to continue looking down, you can, by placing your finger on the margin of the everted lid, hold it in this position and exam- ine it thoroughly. SECOND SERIES (Continued). Part fl. — External Diseases oe the Eyeball AND Lids. In looking for glass on the ball or lid it is usually necessary to use "oblique illumination," as in looking for cataract, which will be described later on. This will show the glass very plainly, the use of a strong magnifying glass will also aid in locating the piece of glass you are searching for. The eye appears inflamed or red ; this may be due to an infectious conjunctivitis, foreign body, ulcer, iritis, irritation, or eyestrain. We will first consider simple inflammation, such as is seen in the case of a foreign body, irritation and eyestrain. This is called "hyperemia of the conjunctiva" and is chiefly confined to the lids and outermost portions of the sclera. These appear redder than normal and the blood vessels of the l)ulbar conjunctiva ; those on the eyeball are large and dilated with blood. There is no discharge, but the patient may com- plain of itching, burning and smarting with a feeling of roughness of the lids, which may upon arising in the morning feel "thick and gummy." DTSF.ASF.S OF TTTF RVE I'ig. IX. — Sinii>le liyi>cr.Tniin of tlie eye (simple inflaiuniatioii.) Fig. X. — Catarrh conjunctivitis (cxaRgcrateiH. Notice the glueing together of the lashes in clumps and the marked inHammation of ilie conjunctiva. AND HOW RECOGNIZED. 23 This is commo;i in eyestrain, either from uncor- rected refractive errors or from any un(kie effort, such as attempting to see through a cataractous lens or corneal opacity. It is also found in smokers, engine drivers, persons exposed to wind, irritating dusts and gases and in a "cold." Notice Fig. IX ; fix this picture in your mind so as to compare it with the congestion of iritis. Next we have inflammations due to infection, which while similar to the above, are more severe and of a more aggravated form with the "muco-purulent dis- charge." This begins with a sensation of smarting and burn- ing, with a feeling of sand in the eye ; the lids usually stick together in the mornings. The conjunctiva of the lids is red and swollen, there is generally more or less photophobia or undue sen- sitiveness to light and profuse lachrymation. Notice Fig. X ; this is similar to Fig. IX, except the eye is more inflamed and the lashes are stuck together in clumps, much as they were in Fig. I of the last series illustrating blepharitis marginalis. The bulbar conjunctiva is markedly congested, the vessels seemingly gorged with blood almost to the bursting point, with more or less "puffiness'* of the conjunctiva; this is more marked at the junction of the lid and eyeball, in the "retro-tarsal folds," as it is called. This disease may accompany "grippe" or even a bad "cold." One form of this disease is highly con- tagious and of a little more severe type and is known as "acute contagious conjunctivitis," or in popular terms, "pink eye," and occurs quite often as an epi- demic, usually in the months of spring and fall. The term pink eye was given it on account of the 24 DISEASES OF THE EVE marked congestion ; "red eye" would perhaps be more applicable. With this latter trouble there is often some eleva- tion of the bodily temperature. Where there is much discharge or great inflamma- tion, the pus should be examined microscopically to Fig. XI. — Pterygium growing from tlie inner cantluis of the right eye; it lias already started to grow over the cornea. Fig. XII. — Leucoma or opacity of the cornea, drayish colored spot on the upper portion of tlie cornea, disfigures the eye, and in this case interferes with vision when looking up, and some impairment of vision all the time, due to haziness of the cornea, which does not show in the picture. AND now RECOGNIZED. 25 cliiniiiatc the uncertainly uf it being gonurrhcal. Gon- orrheal ophthalmia is a decidedly dangerous atfection and the large majority lose their eyes. Another condition commonly met with and one in which there is more or less redness of the eyeball, is pterygium (terig-ium.) This is a growth on the eyeball starting usually at one corner (canthus), and as a rule the inner canthus. They grow very slowly as a rule, and give little or no trouble except in cases where a person's vocation keeps him out of doors in the wind and dust; in such cases they prove very irritating and grow quite rap- idly. They may stand up from the eyeball, as in the "fatty" type and offer a catch-all for any particles of dust that are floating around, or they may lie per- fectly flat and never be noticed unless the eye becomes inflamed, when they will stick up and become notice- able. This is a triangular growth, with its base spread- ing out at the canthus and the apex extending up to- wards the cornea. Its etiology is somewhat obscure ; it is common in people exposed to wind and dust : sailors, engi- neers, farmers, motormen and others whose calling compels them to be out in all sorts of weather are subject to this trouble. It not only greatly disfigures an eye, but renders it more susceptible to inflammation and infection, and it is unsafe to operate on an eye with a pterygium, especially if the operation is one on the iris or lens. A pterygium should be removed before it grows over the cornea. Just as soon as it reaches the limbus it should be removed, sooner if possible, as it destroys the vision if it grows over the cornea. The treatment is purely surgical. The operation is done under local 26 liISEASES OF THE KYE anesthesia, is painless and healing is usually complete within a few clays, without any detention from one's business. Another trouble which may be mistaken for ptery- gium by the uninformed is a leucoma or scar of the cornea. This appears as a white or grayish scum over the same portion of the cornea, usually in the upper part and is generally due to an old case of granulated lids or the scratching of the scar tissue, which follows the healing of the granulations. Burns or injuries also cause this form of opacity, or it may follow inflammation of the cornea, ulcers or the use of strong and irritating medicines, and al- most follows gonorrlical ophthalmia of the new-born. It appears as a dull spot, the edges of which are less opaque than at the center, the cornea surrounding it is usually infiltrated and hazy. The opacity itself varies in size, location and shape. Where the opacity is dense or greatly disfigures it may be tattooed; this is done with various colored chemicals and is very hard to detect if properly done; and iris is painted, so to speak, over the cornea; this has to be done about every six months to make it look natural. Figure XII shows a leucoma on the upper portion of the cornea due to old granular lids ; this is the most common site of its formation, and trachoma is the most frequent cause. AND now RECOGNIZED. 27 PART III. Dtsi'.asks of the Eve. Now that you have learned to "evert the lids" you will be able to diagnose some of the more common lid diseases and the two we will consider in this paper will be follicular conjunctivitis and trachoma or "gran- ulated lids." Follicular conjunctivitis is a form of catarrhal con- junctivitis with the over development of the "lymph follicles." On everting the lids, particularly the lozver one, you will notice numerous small, pale, round semi-trans- lucent spots or granules, which are often arranged in rows extending across the lid parallel to the margin. They are more numerous at the "fornix" or junction of the palpebral and bulbar conjunctiva. In this disease there is a sticky mucus secretion which causes a sticking together of the lids in the morning. The conjunctiva of the lids looks "puffy" and is quite inflamed but the bulbar conjunctiva is not so much affected, it is usually slightly inflamed but not markedly congested as in some of the other dis- eases we have studied. There is photophobia and lachrymation, with the itchy feeling of sand in the eyes, causing the patient to unconsciously rub them. This disease is more com- mon in young people, particularly among those whose surroundings are unhygienic, or where many are crowded together, common among the tenement classes and in schools. As to its being contagious, that question has caused more or less discussion and disagreement among the 28 DISEASES OF THE EYE authorities. There is, however, plausible reason to be- heve that it is slightly contagious, since several mem- bers of a family or a number of pupils of a sing'e school-room will have the disease at the same time. It is not a disease of serious consequences, but is quite aggravating and persistent. It differs very much from trachoma and should not Fig. XIII. Follicular conjunctivitis, bmall round elevations more numerous at the fornix. Eyeball only slightly inflametl; much secre- tion, which causes the lashes to become glued together in clumps. Tliis gluing together of the lashes is not often seen, as\ the patient usually washes his eye before appearing at the ofhce and the lashes may appear straight and normal. he mistaken for it; such a mistake rarely occurs in the diagnosis by the well informed. Remember that this disease docs not affect the deep- er structures of the lid but is confined to the conjunc- tiva proper. The treatment consists in improving the patient's unsanitary surroundings or in removing him AND HOW RECOCINIZED. from them ; correcting refractive errors ; eye-rest ; and looking after the general health, etc. Trachoma or granulated lids is a dirt disease, a dis- ease of the poor tenement classes, it is also highly con- tagious, and because it is so easily contracted it is now seen among nearly all classes of society. It is gener- ally followed by a long train of serious and compli- cated scquelx as we have already seen. Fig. XIV. Early stage of trachoma, seldom seen. Lashes may appear glued together, especially if the cases are among poor tliildren who have not been washed before the visit to the office. Eyeball slightly inflamed, with a few large, prominent granules standing out from the conjunctiva. The acute stage of the disease is seldom seen, unless it is discovered accidentally in testing the eyes, but when the patients come to us complaining of the trou- ble it has, as a rule, reached a more or less chronic stage. The symptoms of the acute stage much resemble those of the other diseases, lachrymation, photophobia with a mucus or muco-purulent discharge, — occasion- 30 DISF.ASKS OF THK EVE ally ulcers of the cornea, — with great swelling and in- flammation of the palpebral conjunctiva with some congestion and pufifiness of the bulbar conjunctiva, and the granulations are usually hidden by the swollen conjunctiva and may be overlooked. We generally see the diseases after the acute symp- toms have partially subsided and the disease has pro- gressed to the chronic stage and the patient may com plain of nothing more than the feeling of sand in the eye, which is aggravated by wind and dust. On everting the lids, — [jarticularly the upper one. — we see a number of irregularly shaped granulations, grayish in color, resembling grains of sago which seem to project from the conjunctiva. They are more abundant at the retro-tarsal folds and are imbedded in the conjunctiva and involve the deeper structures, thus differing from the preceding disease. If seen late in the development of this disease you will notice that some of the granulations have been re- placed by a small shining scar. Later the scars become so numerous that they seem to have coalesced and much of the conjunctiva has been replaced by this cicatricial (scar) t'ssue which causes entropion, trichiasis and pannus with more or less opacity of the cornea. The treatment depends on the stage of the disease, and consists of expressing the contents of the granu- lations by means of various instruments : the opera- tion is quite painful unless done under a general an- esthetic, such as ether or chloroform. The use of the various caustics in this disease is not advisable, because it is impossible to control their action or limit the effects. T prefer the slower and more conservative methods: the ft^-m of treatment I AXn TTOW RKrOONTZF.I). 31 have usrd witli niucli success is that of ['rincc. wliich consists of instillations of a solution of pure copper l"ig. W. Later stage of trachoma. Granulations have begun to heal, leaving scars, which has caused a scum to form over the upper portion of the cornea. Eyeball markedly congested. I'ig. XVI. Last stages of trachoma. Almost the entire upper lid is a mass of scars, which lias caused much scratching of the cornea and has produced a dense leucoma in which there appears small blood vessels (Pannus). The eyeball is in a state of chronic congestion. The disease has progressed too far to ever do much with it, so far as restoring the vision. 32 niSKASES OF THE EYE sulphate in ylyccrinc; this is done every day for a pe- riod of considearble time, the amount of copper be- ing gra(hially increased each week. With this treat- ment instillations of some of the mild astringent and antiseptic collyria are made into the conjunctival sac. The use of the copper sulphate stick is dangerous and the far reaching after-efifects may be as bad as the disease itself. lU.ClCRS OK Till-; COKN'l-:.\. Owing to its metabolism the cornea is prone to ul- cerate after any abrasion of its surface. The presence of various bacteria on the conjunctiva has been dem- onstrated; these micro-organisms readily find a fertile field for growth on an abraded cornea. Ulcers of the cornea are of such frecjuent occur- rence, and the accompanying intense pain and pro- longed suffering, with the serious complications and untoward eiifects which follow, that it behooves every optician to be constantly on the lookout for this disease and make his diagnosis early, so that the patient may have prompt treatment. We conunonly see ulcers after tb.e lodgement of a foreign body in the eye: also after the use of caustics in the treatment of trachoma. The cornea being devoid of blood vessels, its nu- trition is less well assured and its struggle against in- fection less efificient. The first thing we notice in the early development of an ulcer is the localized hazy spot on the cornea, later the central portion of this spot breaks down and ul- cerates, the edges being rough, ragged and slightly un- dermined. Oftent'mcs the entire cornea may lose its glistening appearance and become hazy and look "steamed." AND now RECOGNIZED. There is the most intense photophobia, lachrymation is profuse and the pain is severe. If the ulcer is near the periphery of the cornea, there will be seen a small leash of blood vessels run- ning up to the limbus and the whole conjunctiva will be congested. An ulcer of the cornea is so readily detected that anv more on the diagnosis would be superfluous ; but, FiR. X\ II. Ulcer of the cornea. Notice the small leash of blood vessels extending up to the cornea. The bulbar conjunctiva is mark- edly inflamed and the cornea surrounding the ulcer is less transparent; has a "steamed'' appearance. where any doubt exists, it may be stained with a drop or two of a 2 per cent solution of potassium fluori- cide. This stains the abraded surface and the edge of the ulcer a yellowish-green and the extent of the ul- cer can be readily mapped out. This disease causes much pain of more or less se- verity, the pain radiating over the brow and temple, DISEASES OF THE EVE worse cat night. Profuse lachryniatioii and photopho- bia are accompanying disagreeable symptoms and are quite marked. There is usually more or less blepharospasm and the patient has difficulty in opening the lids, especially Fig. XVIII. Staphyloma of the eye. This is the result of a weakeninp of the cornea due to ulcers. The intra-ocular pressure is so great that the weakened cornea gives way before it. in a bright light. Ulcers always leave a scar with more or less opacity, depending on the amount of tis- sue destroyed. AND now RECOGNIZED. 35 Small shallow ulcers heal without any apparent or appreciable opacify, simply causing a little irregular astigmatism. Deep ulcers are serious. Perforation with loss of the acqucous, prolapse of the iris with adhesions are the frequent complications. There are various forms of ulcers, a discussion of which would render this too lengthy; suffice it to say that any form of ulcer should have prompt and ener- getic treatment. The treatment depends upon the severity of the case, hot, moist applications, afford a grateful relief. Antiseptic lotions and atropine are the usual methods of treating this disease. Occasionally it becomes necessary to puncture the cornea to prevent a staphyloma and to have the per- foration where it will interfere the least with vision. The cornea may become so weak that the intra-ocu- lar pressure causes it to bulge, and the puncture is made to prevent this. We now come to inflammation? of the cornea, or keratitis, as it is called. The first form of this disease we will consider will be interstitial keratitis. This disease may be due to hereditary trouble or may be acquired. It is usually due to inherited taint, and is seen quite often in young adults and children ; it may, however, be found in older people as the result of acquired constitutional disease. There are cases of this form of disease in which no constitutional taint is manifested; it is claimed by some that it may be of tubercular origin. It occurs more frequently in females and usually is seen between the fifth and twentieth year, rarely after the thirtieth. It may occur without any supposed cause, or, as 36 IiISF.ASKS OF THE EYK is niurc often ihc case, it will appear after or during an attack of rheumatism or somft acute febrile dis- ease, or even abuse of the eyes will be sufficient to bring on an attack. Usually one eye is affected at a time, but both sooner or later suffer from the disease. In hereditary cases there will often be found the so-called "Hutchinson teeth," as seen in Fig. XIX. This disease aft'ects the middle and posterior lay- ers of the cornea and starts with photophobia, lacli- I'ig. XIX. — Hutchinson teeth. Pegged and notched variety. rymation, blurring of the vision and "pericorneal injection." The cornea becomes hazy by a faint opacity starting near the limbus and gradually ex- tending over the entire surface, forming a more or less dense, smooth opacity which renders the iris in- visible; later there will be seen minute blood ves- sels running into the deep layers of the cornea. As a rule the iris is affected, and as a result of this iritis synechia may form, the iris adhering either to AND now RECOGNIZED. Fig. XX. — Interstitial Keratitis. Entire cornea white and hazy, except for a small portion at the lower part. Notice the ring of minute blood vessels surrounding the cornea — "peri-corneal injection. A fev capillaries are seen making their way into the cornea itself. Eye greatlv inflamed. Cornea so hazy that the pupil is difficult to see. Fig. XXI.— Punctate Keratitis. Small white deposits on the pos terior surface of the cornea. 38 DTSFASKS OF THE EYE the lens beliind (posterior synechia) or to the cornea in front (anterior synechia). The treatment should be energetic and persistent and consists of general systemic treatment, with eye treatment depending on the symptoms and se- verity of the disease. Fig. XX. shows a well developed case of this disease. Next we have a condition which often accompanies inHanimations of the uveal tract, i. e., iris, choroid and ciliary body. This disease is characterized by deposits on the pos- terior surface of the cornea, and because of the ap- pearance these dots give the cornea the name punctate keratitis has been given to the condition. It is, how- ever, not a disease of the cornea, but only a symptom of a disease of the deeper structures; and where this symptom is shown the examination should go deeper and search for trouble of an inflammatory character of some portion of the uveal tract. As this is only a symptom, we do not treat this, but treat the disease which causes this symptom. There is a disease of the cornea which somewhat resembles this disease, except that the dots are situ- ated on the anterior surface of the cornea and appear as small grayish elevations scattered irregularly over the cornea ; this is usually caused by acute catarrhal conjunctivitis, and is not in itself a dise3.se of any serious consequences; hot applications, together with some mild antiseptic collyrium, is all that is required. There are other forms of keratitis, but they are of comparatively rare occurrence, and we will not con- sider them in this brief paper. Now it generally happens that where any inflamma- tion has involved the cornea, be it an ulcer or injury, AND HOW RECOGNIZED. 39 or a true keratitis, there is always a scar with more or less opacity, depending upon the amount of tissue de- stroyed. There are various names given to these opacities depending upon the density of the opacity. An opacity can be readily distinguished even at a glance. It appears to be a scum or veil over the cor- nea, with or without any inflammation of the con- junctiva. Occasionally a person will complain of poor vision and the eye will look apparently normal, but with oblique illumination you will notice a very thin and delicate veil over the cornea or some portion of it. Fig. XXII.- — Method of oblique illumination for locating opacities of the cornea, irregularities and foreign bodies. Also used in the diagnosis of cataract. Fig. XXII. shows the method of oblique illumina- tion in examining the cornea ; this same method is also employed in examining the lens for the detection of cataract. 40 DISKASKS ( )1- TllK KVK Opacities of the cornea are slow in yielding to treat- ment, but if the opacity is not of too great a density much can be done toward improving the patient's ap- pearance, although clearing up the cornea will in many cases not add greatly to the vision. There are various drugs employed for this purpose; I have found thiosinamine with vibratory massage to act the most quickly. Where the density of the opacity is so great as to involve the deeper layers there is not much to be done except to tattoo the cornea. This re- Fig. XXIII. — Pericorneal injection. A congestion from the an- terior ciliary vessels and found only in diseases of the iris and ciliary body and involvements of the cornea. quires much skill, as the iris must be matched in color and markings and a good pupil be made. The tat- tooing wears oflf in a short time, so that it has to be done about twice a year. We have studied all of the more common diseases now RKCOCNiZKt). of the external structures of the eye, and now pas:i to diseases affecting those structures inside the eye. The first and most common we will consider will be iritis, or inflammation of the iris. There are various causes assigned to the causation of this painful inflammatory disease, but the most com- mon is the same constitutional taint we saw in inter- sitial keratitis. This causes about sixty per cent., and rheumatism causes about twenty per cent., the remainder is divided up among eyestrain, gout, diabetes and other systemic diseases. Fig. XXIV. — Irregular dilatation of the pupil after the use of atropine. Due to synechia or adhesions of the iris to the lens as the result of inflammatory conditions of the iris. This disease is quite painful and begins with pain in the eye and radiating over the brow and temple and over the side of the nose. The eyeball is greatly in- flamed, the deep vessels being involved, giving the eye 42 DISEASES OF THE EVE the appearance as in Fig. XXIII., called pericorneal injection. The pain is worse at night and the eye is sensitive to touch, especially if pressure is made on the upper lid of the closed eye just back of the limbus. Vision is impaired and there is some loss of ac- commodation, lachrymation and photophobia are, as in all inflammatory eye troubles, accompanying symp- toms. The iris has lost its lustre and has a muddy ap- pearance; a brown iris looks yellow, while a blue one will look green. There are usually posterior synechia, so that the pupil does not dilate evenly, as is shown in Fig. XXIV. There are three diseases, of which you should always remember the symptoms and never mistake one fo^ the other; they are conjunctivitis, iritis and glaucoma, and I trust the following table may help you in re- membering the distinguishing characteristics of each disease : CONJUNXTIVITIS. Pupil regular. Pain none, except the burning or smart- ing, or sensation of foreign body, feel- ing of sand. Redness general over the enfcire con- junctiva. More or less discharge. Anterior chamber normal. Cornea sensitive to touch and normal in appearance. Pupil normal in appearance. Tension normal. Seen at any age. Fundus normal. ANn now RF.COCNIZEn. Iritis. Pupil small, contracted. Pain severe, worse at night, in eye and over brow. Redness general, but more intense as a ring surrounding the cornea. No discharge. Anterior chamber normal. Cornea sensitive to touch and normal in appearance. Pupil muddj', lacking in lustre. Tension normal. Usually under 45. Fundus normal. Glaucoma. Pupil dilated. Pain comes on later in the disease. May resemble either one or both of these diseases. No discharge. Anterior chamber shallow. Cornea more or less insensitive to touch and less transparent, "steamed" ap- pearance. Pupil sluggish and may appear muddy. Tension increased. Usually past middle life. "Glaucomatous cupping." 44 DISEASES OF THE EYE The treatment ot iritis depends upon the cause; atropine is the most sedative remedy we have; band- age or dark glasses, rest and constitutional treatment, depending on the cause. It should be treated as early as possible so as not to endanger the sight of your patient and to prevent synechia from forming. One of the most characteristic symptoms is the zone of inflammation surrounding the cornea. Notice Fig. XXIII. again; notice the circle or zone immediately around the cornea. At first the eyeball is only red- dened ; later, as the disease advances, the inflammation becomes more pronounced and the circle or zone just spoken of changes from a pink color to a darker red; this is called the peri-corneal zone or zone of peri- corneal injection. The vessels look as if they were about to creep up over the cornea. Diseases of the Lens The most common, as well as the most frequent dis- ease of the lens, is senile cataract. This disease comes on in old life and is accompanied by other senile changes in the body, such as a hardening- of the blood vessels, etc. The patient will be able to read better while the cataract is forming and may read without his glasses, but his distant vision will be impaired. This is due to the lens becoming more convex during the early stages of the formation of the cataract. The patient sees better on a cloudy day or after sun- down. Where there is any congestion of the eyeball, be sure to look elsewhere for the cause of such conges- tion. A cataract does not cause any inflammation of the eye. This disease is one of very slow progress, and the patient may not be aware of the trouble until years after the formation has begun ; he will probably notice that his vision has become impaired, but never sus- pect the cause. To most of the laity a cataract means a white growth or scum on the eyeball, and any opacity of the cornea or even a pterigium may be called a cataract by them. A cataract is a disease of the crystalline lens — an opacity of the lens, and is not readily noticed until after it is ripe. 46 DISEASES OF THE EYE The vision gradually decreases until the patient can only count fingers, and eventually he loses even that much visual acuity. One or both eyes may be affected at the same time, l^sually. however, one eye is af- fected at a time, or the disease will be more advanced in one than in the other. Both eyes are always sub- iccted to this disease sooner or later; hence, as soon as the lens in one eye is ripe, the cataract should be removed, or where the lenses of both eyes are affected at the same time, the lens most advanced should be needled or a preliminary irodcctomy done, so as to hasten the ripening. Fig. XXV.— Puikije's images; x from the cornea, y from the anterior surface of the lens, and z from the posterior surface of the lens. Remember, there is no medicine nor any form of treatment which will "absorb" a cataractous lens ; an opacity of the cornea can be "absorbed" (?), but not a cataract ; so warn your patients that they are not only wasting money, but that the delay involved while fool ■ ing with various forms of fake treatment may mean the total loss of vision. AND HOW RECOGNIZED. 47 The only cure for cataract is extraction of the lens, an operation requiring' much skill. Opacities of the lens can be* seen by oblique illu- mination, as is shown in Fig. XXII. When a lighted candle is held before the eye and a trifle to one side, you will notice three images, called fhe images of Purkinje, as shown in Fig. XXV; x is the bright, upright image reflected from the cornea ; y is an enlarged image reflected from the anterior sur- face of the lens, while the small inverted image, z, is reflected from the posterior surface of the lens. Fig. XXVI.. taken from Vol. II. of the American Text Book of Physiology, shows the method in which these three images are formed. ,7 , ^r?- ^XVl.— Method of forming the images of Purkinje. From Vol II., American Text Book of Physiology. Also explaining accom- modation as seen with the Phakascope of Helmholtz; a is the corneal image; b is the image formed by the anterior surface of the lens, and c IS the image formed by the posterior surface of the lens; (b' show, the change in the image from the position of b during accommodation). In a cataractous lens, z is absent and y is much dimmed, depending on the stage of the disease; x is unaltered. In these images of the candle flame, x and y move with the flame, while z moves in the opposite direction. 48 DISF.ASRS f)F THE EYE In a case where a cataract is suspected, a mydriatic should he instilled into the conjunctival sac, so as to have a clear view of as much of the lens as is possible. The reflex from the retinoscope or ophthalmoscope will be diminished or lost, dependinj^ on the density of the opacity, and in a lens in which the disease has |)rogrossed very far it will be impossible to see the fundus. There are various forms of cataract which you will find described in the larger works on diseases. Perhaps one of the forms you will meet with quite frequently is wdiat is known as a traumatic cataract, which is no more than an opacity of the lens due to injury, espe- cially frequent in cases where the injury has pene- trated the eyeball and the lens has been injured ; often- times just a touch by the foreign body will be sufficient to start the formation of a cataract. Glaucoma Glaucoma is a disease of the eye in which the canal of Schlemm is blocked up and the fluids of the eye are dammed up so that they do not drain out, causing marked intraocular pressure with degenerative changes in the eye. Glaucoma is an inflammatory disease, with severe pain and congestion of the eyeball, much like that of iritis. There is loss of accommodative power and tem- porary blurring of vision. It usually occurs in persons past middle life ; the an- terior chamber is shallow and the cornea has a steamed appearance, looks as if it had been breathed upon, and the patient will complain of a halo or ring of various colors surrounding lights. The pupil is dilated and sluggish and the anterior chamber is shallow. Tlie attacks come and go, each attack lasting longer and being more severe than the preceding one. Glasses have to be changed frequently. The vision soon becomes permanently impaired and the pain becomes more or less constant, is quite severe and radiates over the eye and temple, the patient at first often mistaking it for a simple attack of neuralgia. The pain soon becomes intense, morphine being about the only thing which will relieve it, and the peri-corneal inj;ection is marked. In the early stages determine the field of vision ; it is always contracted, especially on the nasal side, and as the disease advances the entire field becomes con- r.O DISEASES OF THE EVE tractcd. During an attack the tension is always in- creased and you may compare it with the hardnes- of your own eye. Glaucoma is a disease which requires careful study. and to make a diagnosis in the incipient stages one must be careful to thoroughly go over each detail to make his diagnosis certain. The disease may be pre- ceded by premonitory symptoms, the patient feeling that an attack is coming on from knowledge of past attacks, and where the history points to previous attacks, oftentimes the immediate use of a myotic will postpone or abort an attack. This disease is not found in myopes. To go over the symptoms again I will tabulate them so that they may be more easily remembered: i, There is the pain in eye and over brow, "ciliary neuralgia"" sometimes called ; 2, the venous congestion and ciliarv injection; 3, dilatation and sluggishness of the pupil; 4, increase in refraction ; 5, contraction of the visual field, dimness of vision, halo of colors and scotomata ; 6, cloudiness of the aqueous and vitreous in the later stages or after the attack is well developed, and the "breathed-on appearance" of the cornea ; 7, anesthesia of the cornea and increased tension ; 8, cupping of the disk with pulsation of the arteries of the fundus. Fig. XXVII. shows the cupping of the disk is glau- coma, and Fig. XXVIII. shows a cross section of the disk which explains the reason for the disappearance of the vessels over tlie edge and their reappearance at the bottom of the cup. There is a physiological cupping, but the edges are not undermined, and the vessels are visible all the way down to the bottom of the cup. For a more detailed description of this disease I refer you to some of the standard text books on dis- AND HOW RECOGNIZED. eases of the eye, which take this subject up iu more detail. Fig. XXVII scope. oplithalmo- Fig. XXVIII.— Cross .section of the ilisk, showing reason for the disappearance of the vessels over the else and their conseciuetit re-an- pcarance at the hottom of the cup. 52 niSKASF.S OF THE EYE Other diseases which involve the retina can be studied from the text books. The ones which the op- tician should be able to recognize are some of the more common inflammations, such as retinitis albumin- urica, retino-choroiditis and simple congestion of the retina. He should also be able to recognize atrophy of the nerve, detachments of the retina, interference willi the circulation of blood in the retinal vessels and degenerative changes of the retinal elements. "Haab's Ophthalmoscopy," in the form of Saunder's Hand Atlas, is perhaps the best book for the optician. We have now considered most of the more com- mon diseases of the eye with which you are likely to meet. Injuries are of so rnany forms and degrees that it would be impossible to undertake a description of them. I might say a few words about diseases of the lachrymal apparatus, as it forms a very common disease. There is the simple closure of the nasal duct, which causes the tears to flow over the cheeks; this usually means trouble in the nose and the patient should be referred to a specialist for treatment or an operation on the nose. Quite often the duct is closed from a stricUirc, and the gradual dilatation by probes or sounds will effect a cure without any operative inter- ference in the nose. This method of treatment is comparatively painless, and a few treatments usually effect a cure unless there is trouble in the nose, block- ing up the nasal outlet of the duct. If there has been any interference with the passage of tears down the nasal duct for any great length of time, the dilated upper portion of the duct, called the sac, may become infected and pus form in the sac, AND HOW RECOGNIZER 53 which causes ^ bulging of the skin in that region and may swell up to the size of a pigeon's egg. The skin becomes tense and somewhat reddened ; the lower lid is swollen partly shut, and slight pressure over the region of the swelling may cause a drop or two of pus to escape through the lower or upper punctum, or both. Any swelling in this region may be taken to mean a diseased condition of the sac. which calls for prompt treatment. Fig. XXIX. — Retention of tears or pus in the lachrymal sac, causing a swelling in that region. Fig. XXIX. shows the swelHng in retention of tears or blennorhoea of the sac, as it is sometimes called, and if the contents are infected the term dacryo- cystitis is given it. This concludes the series on the more common dis- eases of the eye, and I trust will help the optician in making a diagnosis and refer his patient to an oculist 54 DISEASES OF THE EYE fur early treatment, and tliiis raise the practice of op- tometry, so that it will be looked upon as a profession and not a business. The optometrist should be educated to the highest point of efficiency. He now surpasses most oculists and "medical refractionists" in his knowledge of the optical principles involved in the scientific application of lenses, but he siiould be more than this ; he should know anatomy and physiology of the eye, and shouM be able to recognize the more common diseases of the eye; thus would he surpass the family doctor. He should be able to handle the ophthalmoscope in- telligently and diagnose the more frequent pathological conditions of the retina and nerve. I hope this little series will stimulate you to the reading more of diseases of the eye and act as an in- centive for a broader knowledge in this interesting field of study. Another point before closing. Read your trade journals — they play a very important role in the de- velopment of American business. The ideas and ex- periences of others are at your disposal through their columns, and the results of the investigations of the optical world are right at your hand. You will get suggestions and pointers which will be invaluable to you. Your trade journals put you in touch with the thinkers, with men who plan and do things, and it keeps you posted as to what is going on in your pro- fession. With optometry laws in many of the States (and more to follow), people are waking up to the fact that the practice of optometry is a professional field, and not one of pure commercialism, as was for- merly supposed. In illustrating this series I have had the able assistance of Mr. Poole. I also desire to thank my ofWcc girl for many poses for pictures. The Eyes of School Children The Frequency of Refractive Errors — The Value of Their Detection and Correction — The Influence Upon the Mental and Physical Condition^ — The Economic Value of Vision The Eyes of School Children Ours is a progressive age of enlightenment. Scien- tific men the world over are giving daily to the world new and startling discoveries. Various diseases have been studied experimentally, bringing science to bear upon the alleviation of suffering and the longevity of the race. And yet with all these great scientific researches and wonderful achievements by men of science, we are only now awakening to the fact that the furtherance of such search and inquiry into unknown fields and the solving and accomplishment of other scientific and business problems depends on the development and health of the coming generation — the school children of to-day. This city (Spokane) has started this year aright with the examination of its school children by special- ists, who devote their time to the searching out of any diseased or defective children, educating both pupils and teachers in school hygeine and throwing out safe- guards for the protection of life against disease, that the future of this city may be preserved in the devel- opment of a healthy lot of boys and girls. There are two of the special senses which, when de- fective, greatly modify the physical as well as the mental development of a child— seeing and hearing. Since the former is the more important and its defects AND now RECOGNIZED. 57 the most frequent, I shall consider it in this brief paper. It will be my purpose in this contribution to give such information as will, I trust, convey the manner in which the eyes can and do affect the mind as well as the body ; to demonstrate how the results of unrecognized and uncorrected defects of the eyes and o.S2§8gSSssSgS.esSS§S3 Table showing refractive errors and percentages at different ages of school life. II. Curve of myopia. I. Curve of emmetropia. schools. III. Curve of emmetropia. IV. Curve of hypermetropi of myopia. Erismann — St. Petersburg. VI. Curve of hypermetropia. Risley — Philadelphia. Risley— Philadelphia v. Curve anomilies of the extra-ocular muscles do create and perpetuate nervous, physical and mental derangements. The results of the examinations of over two hun- dred thousand school children of all grades, by Euro- pean and American observers, furnish the data from which the statistics regarding the frequency of refrac- tive errors have been compiled. From Fig. i it will be seen that emmetropia remains r.8 niSEASF.S OF TTIK EVE almost constant in the various ages, while hypermc- tropia gradually decreases among the school children in the higher grades, while the percentage of myopia increases in the more advanced classes. The percentages are shown diagrammatically by curves; notice the curve of myopia (2); at the age of eight and a half years there was found only 4.27 per cent.; after that age there is a gradual increase until at the age of seventeen and a half years it has reached 19.33 P^^ cent. Curve of myopia (5), from Erismann's examina- 2 OymnasiuBS Figure II. Showing increase in percentage of myopia in the higlier grades, in direct proportion to the length of time devoted to school life. Made from Cohn's statistics. tions of the school children of St. Petersburg, shows a much larger percentage of myopes, ranging from 18.C per cent, in the young children up to 42.8 per cent, in the more advanced classes, up to the age of thirteen, against the 19.33 P^r cent, at the age of seven- teen and a half years in the Philadelphia schools. Risley found 36.2 per cent, of hyperopia in the Philadelphia schools, whereas Erismann found 66.84 per cent, in the St. Petersburg schools. AND now RECOGNIZED. 59 Colin examined the eyes of ten thousand and sixty school children in Breslau and vicinity, and Fig. 2 shows, diagrammatically, his findings. There is the same increase of myopia from the lowest to the highest grades ; in the primary grades only 1.4 per cent, were myopic, while in the gymna- siums the percentage of myopia had increased to 26.2 per cent. From these tables of results we may very properly conclude that this increase of myopia is due in direct proportion to the length of time devoted to school life — the length of time the child has been subjected to eye strain. This continuous progression of myopia has been verified by numerous observers in this coun- try, as shown by Risley's arrangement of Randall's tables, page 357 of Norris & Oliver, Vol. 2. While the percentage of myopia among the ad- vanced students is not nearly so great in America as in Europe, yet the same significant fact confronts us : myopia is on the increase. Most children start to school between the ages of five and six, at an age when the eyes are not fully de- veloped, no more than the remainder of the body, and it is by no means equal to the tax imposed upon it by constant use in study. The refractive condition of the eye in early child- hood is nearly as often hyperopic as it is emmetropic, and the strain upon accommodation as well as upon convergence is greater than evolution has provided for. A child, unlike an adult who reads a line or sentence at a glance by comprehending the general appearance and arrangement of the letters, has to study each letter of every separate word, just as an adult would have to do in reading an unfamiliar foreign language. Now if the eye be hyperopic, as the large percentage usually 60 DISEASES OF THE EYE arc, it means an increased amount of accommodation is called into use. The internal recti and the ciliary muscles normally act together, the recti turning the eyes in one metre angle for each dioptre of accommodation. An emmetropic eye is absolutely passive in looking at infinity: objects 20 feet or more away; anything closer than this is focused by the action of the ciliary muscle, and at the same time binocular vision is main- tained by the action of the internal recti. If the child is hyperopic, the eye is never passive; it must accommodate for distance as well as for near obj.ects, hence it does not have a chance to rest; not only is the accommodation working overtime, but there is the unconscious act of convergence with it, paral- lelism of the visual axes being maintained by action of the external recti — more abnormal expenditure of muscular efforc with the dissipation of nervous energy. In reading, the strain is even greater than for dis- tance, since there will be more meter angles of con- vergence than is required for the distance at which the child is reading. This extra strain will not be long tolerated, if the refi-active error amounts to considerable, as the child will "fix" with one eye and allow the other to deviate, with the resulting "squint" or "cross-eyes." On the other hand, if the child is myopic he will be unable to see distinctly at a distance and will prefer study to outdoor play; but here the strai-n is not so great and does not produce the nervous and physical derangements that hyperopia does; the danger in my- opia lies in the development of "progressive myopia ' — a very serious condition. Myopes are referred to the specialist more often than arc hyperopes, as a myopic child is usually con- AND HOW RECOGNIZED. 61 scious of his defect or very soon manifests it by his poor sight for distant objects — across th^ room or the blackboard. Low degrees of "near-sightedness" are not as a rule noticed, and the child may be conscious that his eyes are not normal ; these cases are by no means rare and are the result of the constant strain upon the eye and its appendages. Eye strain is the forerunner of myopia, and it is unreasonable to conclude that the myopic eye is along the lines of normal development, but rather a disease. Souter thinks the change from hyperopia or emme- tropia to myopia is not of any serious consequence in the average case. He says : "In the natural course of growth there occurs an enlargement of the eyes with the consequent diminution of hyperopia, and normally hyperopia passes into emmetropia before adult life. But in a certain proportion of cases the increase in axial length is not arrested when emme- tropia is reached, and a condition of myopia results. This is probably caused by stretching the sclera by muscular pressure and traction in the convergence required in school work. This kind of myopia does not reach a very high degree, and it ceases to advance after the sclera has acquired its normal resisting power in adult life. It is, therefore, called benign or school myopia." The general concensus of opinion is that myopia al- most invariably follows eye strain, usually coming on after the eighth year, and can be attributed to faulty position of the desks or seats, holding work too close, insufficient or improper light, etc. Myopia is never congenital, but may be inherited, since myopic parents are apt to have myopic children ; and as Ball says, "Just as the susceptibility to tuberculosis is passed G2 DISEASES Or THE EYE from parent to child, so may the tendency to myopia be inherited." He further states that myopia is just as truly a disease as is tuberculosis, since there is the same tendency to develop myopia as there is to con- tract tuberculosis under the proper conditions favor- able to its development. From a careful study of this disease the conclusion seems inevitable that the strain of constant work at the near point is the cause of myopia, and that this cause is more potent during the growing period — the school life — of the child. Whenever a child in apparently good health discards outdoor play for reading, it is generally due, not as some people like to suppose to the child being pre- cocious, but to "near-sightedness." Much time end study has been spent in the hygiene of school rooms, the lighting, printing of books, spacing of the letters, the width of the pages, size and leading of the type, and other changes. The vertical system of writing has been introduced, and more time is given to blackboard exercises and to oral instruc- tion, while the amount of "night work" required is much less than formerly. And while all the advances have had the endorse- ment of all intelligent persons, yet the disappointing fact still remains — there is much uncorrected eye strain among school children which will eventually result in myopia. "Far-sighted" children, on the other hand, have re- markably acute vision, and usually excel in outdoor sports. Study to them is irksome and reading a bur- den, and these are the very cases that are seldom given the early attention which they should by all means have. Parents and toarhers wi'l tell you of the child's keen AND now RECOGNIZED. 63 sight, being able to distinguish small objects which they themselves are unable to see, and because the child can read 20/20 it is oftentimes difficult to per- suade them that the child is sufferinof from eye strain and needs the attention of a competent refractionist. It is not because the child is lazy that he prefers out- door sports to study, but because of his defective eyes play and outdoor life gives to his eyes a grateful feel- ing of relief and comfort, while study brings on a headache or other symptoms of asthenopia due to ocular strain. The old-time idea "that to put glasses on young children so weakens their eyes that they cannot get rid of the habit of wearing them," is entirely errone- ous and due to ignorance on the part of parents, teach- ers and friends. Glasses relieve the trouble and tend to make a perfect eye of an imperfect one, with the result that the child prefers not to do without his glasses ; has no desire to have imperfect eyes again with all the attendant troubles ; and because he wants that which gives him comfort, the lay person is apt to think that he has "weakened" his eyes to such an extent that he can no longer get along without the aid of glasses. Eye strain means nerve drain. It requires a stimu- lus to make muscular fibres contract, and this stimulus is nerve enegry. A hyperopic eye is always active ; never passive, never at rest; constantly using up nervous energy from the time the eyes are opened in the morning until they are closed in sleep at night ; constantly receiving visual impressions of some kind, even unconsciously; yet these pictures must be accurately focused, as near so as is possible with the defective eye, for the brain will not long tolerate a blurred picture without producing ';i mSEASKS OF THE EYE nausea or astlicnopia. In other words, an eye of this kind is using more than its normal supply of nerve energy. The effects of this incessant drawing upon the brain's storehouse is soon manifested by various disturbances of the nervous system, for any excessive or abnormal expenditure of nervous energy to any one particular organ is furnished at the expense of others sooner or later. Not always is this constant drain upon the nervous system manifested through the eyes, but more often through reflex disturbances of the body, sleeplessness, headaches, indigestion, chorea, inability "to fix at- tention," and other various nervous and mental dis- orders. That eye strain is a potent factor in the causation of many nervous and physical disorders is substanti- ated by an abundance of clinical data, and is cited as an etiological factor by many neurologists in works on diseases of the nervous system. Imbalance of the extra-ocular muscles always fol- lows simple hyperopia or hyperopic astigmatism and greatly adds to the already large burden upon the brain and should be looked for in every case of refraction among children, and if found to be of any large de- gree should be restored to their normal equilibrium by muscular gymnastics and not by the use of prisms. Twenty-six to forty per cent, of school children have refractive errors of enough magnitude to be corrected ; errors that demand correction early in life, for the strain resulting from these high errors in time pro- duces a nervous irritability which is analogous to nervous prostration in adults. In drawing conclusions we should remember that tlie eyes of the Indians, Patagonians, Laplanders, the AND now RECOGNIZED. 65 peasant classes of Europe, and among the farmers of this country, do not become myopic, nor do others who follow outdoor life have myopia ; only those whose em- ployment of the eyes at close range ever suffer from myopia and other refractive troubles. Since the negro has been freed from slavery and has taken up the white man's ways of living and is devoting some time to study, myopia has begun to appear among that race. Another point to remember in closing is the fact that the change from hyperopia to myopia is accompanied by a train of pathological symptoms, such as head- aches, painful eyes, undue sensitiveness to light, in- creased lachrymation and impairment of vision, all of which are aggravated by work at the near point and subside upon rest of the eyes, but reoccur as soon as work is resumed. There is almost always spasm of the accommodation, more or less retinitis and choroiditis, with congestion of the eyeballs. If this condition persists for any length of time un- corrected, there is an increased refraction of the eye. This process is by no means a physiological one and is far from being along evolutionary lines ; it is, there- fore, obvious that these symptoms are but the fore- runners of a stretching of the ocular coats with in- creased axial length in the antero-posterior diameter of the eye with consequent staphyloma of the pro- gressive myopic eye. We have improved the hygienic conditions of the school room, have given attention to the books, etc. ; now come the questions, "How are we to get at these cases and give them the treatment they require ? How can the tests be made on so large a scale?" The teacher could at the beginning of each school «6 DISEASES OF THE EYE year make tests at 20 feet with a specially prepared test type, testings each eye separately, and if the vision in either eye fell below 20/20 she should make note of the fact and have the child consult a competent oculist or optician. She should also note whether or not the eyes are inflamed, what trouble the child com- plains of, headaches or eye pain, and the frequency of the symptoms of eye strain. V,i,.J-T?.»<,r£y* /T|0 ^eAo-«' W«.,. tV-e^ ju«.^L,X.«_ £^/v *« j»f T»<# Sm^e OifriM<.f>.f? ^^LC.-^ "^ . 0»BS He wefn6^»ti£.i'> A't^ fl^r o HS.K tnut Puct mn^i'? J^^^ • By keeping a record of such cases on a small card such as is shown in Fig. 3 would enable the teacher to co-operate with the specialist and aid very materially in rapid work of examination. Teachers should be instructed to advise the child of any faulty position of the head or book and should so seat the pupils as to get the proper height of desk and seat for each individual student. Ordinarily children should not enter school before the age of eight years, and should do no outside read- AND HOW RECOGNIZED. 67 ing or studying until the age of eleven. The habit of reading novels and stories of exciting adventure should be discour-aged ; books should be interesting enough to hold the child's attention without effort, but should not be of such nature as to cause excitement and over- stimulation of the accommodative apparatus. The examination of children's eyes should be a part of the routine duty of the teachers or the physicians making the medical examination of the schools, as it may mean the saving of several pairs of eyes each year, and will enable the child who has refractive errors to do better work. As to the economic value of vision, we have no basis for the value of vision from a scientific stand- point; it is a supposition generally accepted that a blind person is totally incapacitated for work in any of the trades or professions. Vision is the principal factor considered in any vo- cation, for upon one's ability to see and see well de- pends his chance for securing employment. Persons mentally deficient cannot be considered, since they play very little or no part in social economics, except as a source of drain upon the revenue resulting from direct taxation. The loss of the sense of hearing does not debar one from entering upon certain occupations, nor does the loss of an arm or leg exclude one from a gainful calling, but the loss of only one eye will often- times prevent one from many forms of livelihood. The value of eyesight has not been estimated from a financial standpoint, it being the rule to value it ac- cording to the earning capacity at the time of injury; the various accident companies place the value of one eye from one to five thousand dollars, while loss of vision of both eyes is usually placed at about triple that amount. 68 DISEASES OF THE EVE Railroad employees are required to have good vision, likewise the men of the army and navy, and in many other vocations good vision is absolutely essential. Partial loss of vision of one or both eyes is not con- sidered, from a financial point of view, to be of any serious consequences, yet it prohibits one from enter- ing nearly all occupations, yet it is not, as a rule, con- sidered by the insurance companies. We may in time get at the true economic value of vision from a scientific standpoint, but as yet we are far from it, the value being placed at about half the loss of earning power. ALL THERE IS TO BE KNOWN ABOUT THE ANATOMY OF THE HUMAN EYE IS TO BE FOUND IN OUR Manikin of the Human Eye 04 Parts, in colors of nature, so you can see and handle tlieni Comprehensive Text Book, all complete, for $1.00 per copy FREDERICK BOQER PUB. CO., 1 Maiden Lane.N. Y. o o u O O I u O H S 3 lit •2 u- " O.S s « i u -O O |o si i « io O c/3 ■5 I • 21^ -a c o c L» u - o o 3 S) ' l-S ^ (b'o f U o ii " c I" E = I g O a J E 3 ^ "5 H O 00^ » 2 o O E = c on -0: ;3B «3 ^.sf tfl t ., I^J 3 C |- 1-1 V 2 c .2- Transpositions A CLEAR EXPLANATION OF AN OPTICAL DIFFICULTY 32 Pages and 39 Diagrams by R. M. LOCKWOOD PRICE 25 CENTS "Bhe Frederick Bo^er Publishing Co. 1 Maiden Lane :: :: New York Tried *"«* True BIGGER, BRIGHTER BETTER THAN EVER Always good, but never so good a.9 now 5,000 paid subscribers. 15,000 readers, comprising all live and progressive deal- ers in opti-al goods and practitioners in optometry. No schemes or special numbers. The Optical Journal comes out once a week, the first issue of each month being a large magazine. Vou may advertise in your own time and way," being assured th'at in the pages of The Optical Journal you get the widest possible circulation among people who are interested in optics..' Frederick Boger P\ib. Co. 1 Matden Lane. New Vork Encyclopedic Optical Dictionary By JAS. J. LEWIS, Oph. D. 1 ( 60 LEWIS POCKET \ OPniCAL DICTIONARY 01 ll hotter than that o( eserine. and does not act aa -r Eiotrepla (ex-o-tro'-pl-nh). When the eye is turned powerfully aa the latter, but is not accompanii-d 1 outward from parallelism. Divergent strabismus. M any unpleasant complications E.erlne .s Exirartlon (ex-lrak'-shun). The removal of a body i 1 1 r< served loi those cases in which pilocarpine mifTcctual. by surgical means. ( vi:;' •^^^^^^V 1, dtMatt inward, usually caused by hyperopia. ^^daHHJI^^Nv I^.lropla (c-so-tro'-pi-ahV 'This term expresses a 1 y^fl^^^^l^^Brvx iiurii;. r niraninR than Esophoria. in which there l^^^fjfl^^^^^^^^^^^H^VV ,. 1, imnly a tendency, while in Esotropia there is :| i^KiS^^^^^^^^^^^^^CJvK. ," a po^tive and visible appearance of the eyes HRgs^^^^^H^^^^^^HhttlkX ,''5jl luriung inward ti,: ^m^^BB^u^HKM \flk\ • 'ifm nicataUoD (cx-cav-a'-shun). Excavation of optic i' jJBWWHHwB||B|^» ' fSbX 'aI nerve, cupping or hollowing of the optic disc. 'llwr^^^^^SB ' 1 5 IjnH Eiophorla (ex-o-fo'-ri-ah) A tendency of the eyo iVf B^ A'#/ 'Mi to deviate outward r, M Exophthalmic Goiter (eks-off-thal-mik goi'tcr). A Vvt '^spW/ Ft V>^ jn^B^Jr Basedow's disease; Graves' disease. The most !•' >(Vlt^ -^^^mW/ prominent symptoms are protrusion of the eye. 1 i^^^^it^ ^n^R^ excited action of the heart, enlarged thyroaf 1 ^^SS^S^sB^i^ (goiter), and certain nervous phenomena. The r'li ^"^^^^^^^^I!!^^ 1? Em not infrequently greater on the right side The upper hds do not follow the eyeball in looking li'i' Eye. The organ of sight. The function of each down (Von Graefe'a sign), infrequcncy of involun- tary winking (Stellwag's sign) and abnormal width of the palpebral aperture are also found. eye, taken singly, is to form upon the retina, or nervous membrane which lines the Inside and back part of the organ, a sharply defined inverted image of any object looked at. The eye resembles a photographer's camera, inasmuch as the image produced upon the retina is precisely the same as that produced on the ground glass of a camera. EioiTHUim. Protrusion of the eyeball. ill By means of the optic nerve the image that is received on the retina is conveyed to the brain, ONE-HALF THE ORIUINAL SIZE SOME OF THE GOOD POINTS A complete dictionary of the terms used in Optometry and Ophtlialmometry. A clear presentation of the wave theory of light with plates A concise yet thorough explanation of the Anatomy. Fuuctiond a Practical hints, things to be remembered and questions and ans State examinations. 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