OpbtbaMogy fhuA / or FROM THE OPTOMETRIC LIBRARY OF MONROE JEROME HIRSCH (V'f/ THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA GIVEN WITH LOVE TO THE OPTOMETRY LIBRARY BY MONROE I. HIRSCH, O.D., Ph.D. A TEXT BOOK OF OPHTHALMOLOGY BY JOHN W. WRIGHT, A. M., M. D. Professor of Ophthalmology and Clinical Ophthalmology in the Ohio Medical University; Ophthalmologist to the Protestant and University Hospitals, Columbus, Ohio. / l\jl ^^^C-c^ /V^^/>* COLUMBUS: J. L. Trauger, Printer and Publisher J 896 ■ ^1 /; OPTOMETRY c >^G PREFACE. CHE object of this treatise is to provide the iiied- ieal student with a systematic text in the pri- mary principles of ophthalmology, such as will be a reliable assistance to him in his pursuits of knowledge as a student of medicine. Xo apology can be necessary for the issuance of a work of this kind, when it is known that there is not a treatise that is particularly designed for the student in his class work in college, most works being intended for the skilled oculist. The arrangement of the subjects has been made in keeping with the needs of the student: first the anatomy and physiology of the eye, then the diseases and their treatment in such natural order, that the subject treated is designed to prepare him as well as possible at each recitation for that which follows. While this treatise is especially intended for the student in his class work at college, it is no less adaptable for him as a general practitioner, for what is necessary for the student to know^ and understand thoroughly, in reference to a knowledge of the anat- omy, diagnosis and treatment of an affection of the eye, in the most concise and practical form, is equally suited to the general practitioner. Another important feature of this work is the olossarv, or rather a limited dictionary of not only all the terms used in this treatise, but all terms relat- iv PR K FACE. iiig to the ryr so far as it has Ixmmi possibh^ to gather them. This I coiiccixc will serve to save time in yearehiiiii for the meaiiinjj; of a word aud often pre- vent the student from passing it entirely, for if his medical dictionary should not happen to be at hand, the ^^'ord is often passed and perhaps not referred to again. The pronunciation of the word is also a feature not to be neglected by the student, for whatever ]»r()nunciation he has been allowed to use at school, be it right or wrong, is generally carried throughout life; for this reason it has been the effort of the author to obtain the latest up-to-date i^ronunciation of all words used in this text. This part of the work has been under the supervision of Prof. G. M. Wa- ters, to whom I am under many obligations. As the plan of recitation in medical schools is fast superseding that of the lecture, it has been my endeavor to so arrange the matter that it may be especialh^ adapted to that method. The subjects, thereof ore, are conveniently ar- ranged in sections of about one recitation each, and the paragraphs are so condensed that the teacher can, at a glance, intelligently frame his question. I am much indebted to mj late assistant. Dr. D. L. Cowden, and my son, C. C. Wright, for their kind assistance in compiling the glossary. This has been an arduous work, the completeness of which attests the painstaking endeavor to make it as pre- cise, and at the sann^ time, as explicit as possible. Many of the delinitions in the glossary have been taken word for word from Duane and Thomas. PREFACE. V As it has been my desire to obtain the most explicit dehnitioiiKS, and as I have found those which I have taken from the above authors all that could be de- sired, I herein acknowledge my indebtedness to them. During the preparation of these pages, the fol- lowing works have been freely consulted, and any matter which was considered as particularly advan- tageous to the student, has been utilized and ar- ranged to conform with the conception of this work. Diseases of the E^e. DeScliweinltz, Text-Book of Ophthalmology. Fiiclis. Diseases of the E^^e. MacXamara. Swanzy on the Eye. Human Physiology. Flint . Gray's Anatomy. Leidy's Anatomy. Ophthalmology and Ophthalmoscopy. Srhmidt- RUnpler, hy Roosa. Hare's Therapeutics. Student's Aid in Ophthalmology. WaRrr. Diseases of the Eye. Xoijcs. Diseases of the Eye. Meyer. It now remains for me to particularly acknowl- edge the kind assistance of my friend, Mr. Fred J. Heer, who, together with the employes of the Luth- eran Book Concern, has had charge of the mechan- ical work. It has been their constant effort to bring this part to the highest possible standard. John W. Wright. 141 East Long Street, Colinnbus, 0. LIST OF ILLUSTRATIONS. FIGURE. PAGE. L Lachrymal and Meibomian Glands (J 2. Lachrymal Canals and Sac 1) 3. Section of the Eyeball 11 4. Choroid Coat of the Eye 15 5. Ciliary }iluscle 18 6. The Choroidea and Iris 21 6. Veins of the Choroidea and Iris 21 7. Segment of the Choroidea and Iris 23 8. Optic Tracts, Commissure and Nerves 30 9. Head of the Optic Nerve 34 10. Vertical Section Antero-Posteriorly of the Eyeball .... 37 11. Blood-vessels of the Eye 42 12. Lymph-passages of the Eye 45 13. ■Muscles of the Eye 46 14. Canaliculus Knife 63 15. Introduction of the Nasal Probe 64 16. Operation for Ectropion 80 17. Operation for Ectropion 82 18. Operation for Ectropion 83 19. Operation for Ectropion 83 20. Operation for Symblepharon 90 21. Operation for Blepharophimosis 91 22. Pterygium 114 23. Persisting Pupillary Membrane 172 24. Wright's Operation for Cataract 236 25. Wright's Operation for Cataract 236 26. Wright's Operation for Cataract 238 27. Foreign Body in the Eye 254 28. Enucleation of the Eye 258 29. 30. Principal and Conjugate Foci 263 31. 32. Optical Illustration 264 33, 34. Optical Illustration 265 35. 36. Optical Illustration 266 37. 38. Optical Illustration 267 39, 40. Optical Illustration 269 41. 42. Optical Illustration 270 43. Operation for Strabismus 286 (vi) LIST OF ILLUSTRATIONS. vii FIGURE. PAGE. 44. Trial Case 291 45. A. Trial Case 292 45. B, Trial Frame 293 46. Test Type 294 47. Astigmatic Test 295 48. Muscle Test 315 49. C, Orthophobia 317 49. D, Heterophoria 317 49. E. Maddox Test 318 50. Plane Mirror for Retinoscopy 336 51. Optical Illustration 340 52. A and B, Loring's Ophthalmoscope 341, 342 53. Optical Illustration 343 54. Optical Illustration 344 55. Normal Fundus Oculi 346 56. The Perimeter 352 57. Perimeter Charts 354 58. Placido's Disc 356 59. Ophthalmometer 357 60. 61 and 62, Illustrations in connection with the Ophthal- mometer 358 63. Double Fixation Hook 360 64. Beers' Cataract Knife 360 65. Levis' Lens Scoop 360 66. Lens Scoop 360 67. Curved Cataract Needle 360 68. Knapp's Needle Cystotome 360 69. Dix's Spud 360 70. Beers' Cataract Needle 360 71. Stevens' Tenotomy Hook 360 72. Payne's Pterygium Knife 360 73. Gruening's Cautery Probe 360 74. Strabismus Hooks 360 75. Knapp's Cystotome 360 76. Keratomes 360 77. Paracentesis Needle 361 78. Stevens' Tenotomy Divulsor 361 79. Curved Scissors, blunt point 361 80. Stevens' Tenotomy Scissors 361 81. Curved Iris Scissors 361 82. Manoir's Scissors 361 83. Straight Iris Scissors 362 84. Noyes' Iris Scissors 362 85. Wecker's Iris Scissors 362 86. Liebrich's Iris Scissors 362 viii LIST OF ILLUSTRATIONS. FIGURE. PAGE. 87. Cilia Forceps 362 88. Fisher's Iris Forceps 302 89. Stevens' Tenotomy Forceps 362 90. Dressing Forceps 362 9L Desmarre's Entropium Forceps 363 92. Bowman's Lachrymal Probes 363 93. Stevens' Needle Holders 363 94. Desmarre's Lid Retractor 363 95. Stevens' Tenotomy Eye-Speculum 363 96. Universal Eye-Speculum 363 97. Strabismometer 364 98. Andrews' Aseptic Syringe for Anterior Chamber 364 99. Aseptic Atropine Dropper and Bottle 364 100. McCoy's Aseptic Eye Shield 364 101. Andrews' Eye Shield 364 CONTENTS. ERRATA. Page o, for " foraminea" read "foramina/' H, for "infraorbita " read "infraorbital." " 4, for "fossae" read "fossa." 7, for "conjunctiva" read "conjunctivae." " 10, 41, 43 and 76, for "palpebra" read "palprebae. 13, for " Descement's" read " Desceniet's." 17, for "tendenously" read "tendiuously." 23, for "are" read "is." 33, for " retina " read " retinae." " 41, for "palpebra" read "palpebrarum." 52, for "preferance" read " prefereuce." " 54, for "subaceous" read "sebaceous." " 61, for "dac3^rocystitis" read "dacryocystitis.'" " 62, for "abcess" read "abscess." " 96, for " muce " read " muco." " 117, for "pterygiun" read "pterygium." 157, for " Decemet's " read "Descemet's." " 165, for "tract" read "tracts." " 169, for "Paracentisis" read "Paracentesis." 361), for "canaliculis" read "canaliculus." viii LIST OF ILLUSTRATIONS. FIGURE. PAGE. 87. Cilia Forceps 362 88. Fisher's Iris Forceps 302 89. Stevens' Tenotomy Forceps 362 CONTENTS. CHAPTER I. ANATOMY AND PHYSIOLOGY OF THE EYE. PAGE. Section I. Defiuitions — The Orbits 1-4 Section H. The Lids — The Conjunctiva — The Lachry- mal Apparatus 4-10 Section HI. The Eye-ball — The Sclerotica — Tunica Vas- culosa 10-14 Section IV. The Choroid — The Ciliary Body— Ciliary Muscles — Ciliary Processes 15-20 Section V. Iris — Pupil 20-27 Section VI. Retina — Optic Nerve 27-36 Section VII. Media of the Eye —Vascular Supply 36-43 Section VIII. Lymphatic System — Muscles of the Eye. . 43-48 CHAPTER n. DISEASES OF THB ORBIT. Diseases of the Orbit 49-56 CHAPTER III. DISEASES OF THE LACHRYMAL GLAND AND LACHRYMAL APPARATUS. Section I. Diseases of the Lachrymal Gland 57-60 Section II. Diseases of the Lachrymal Apparatus. . . . 60-67 (ix) cox TENTS. CHAPTER IV. IN7rRY AND DISEASES OF THE LIDS. PAGE. Section I. Injuries of the Lids 68-69 Sections II. and III. Diseases of the Lids with Opera- tions on the Lids 69-92 CHAPTER V. DISEASES OF THE CONJUNCTIVA. Section I. Hyperaemia— Conjunctivitis (Serous, Muco- purulent, Purulent, Plastic.) Pterygium 93-120 CHAPTER VI. INJURIES AND DISEASES OF THE CORNEA. Section I. Keratitis (Interstitial, Punctate, Vascular, L^lcerative, Suppurative.) 121-149 Section II. Staphyloma — Wounds — Fistulae — Arcus Senilis 149-153 CHAPTER VII. INJURIES AND DISEASES OF THE SCLERA. Injuries and Diseases of the Sclera 154-155 CHAPTER VIII. DISEASES OF THE IRIS. Section I. Iritis (Serous, Plastic, Parench3-matous.) ... . . 156-164 CONTENTS. xi PAGE. Section II. General Considerations of Iritis — Cysts of the Iris — Congenital Malformations of the Iris — Opera- tions on the Iris . . 1G5-175 CHAPTER IX. DISEASES OF THE CHOROID. Diseases of the Choroid 176-187 CHAPTER X. DISEASES OF THE CILIARY BODY. Diseases of the Ciliary Body 188-189 CHAPTER XI, DISEASES OF THE RETINA. Section I. Retinitis ( Albuminuric, Syphilitic, Glycosuric, Leukemic.) 190-199 Section II. Detachment of the Retina , . . . 199-202 CHAPTER XII. DISEASES OF THE OPTIC NERVE. Diseoses of the Optic Nerve 203-208 CHAPTER XIII. GLAUCOMA. Glaucoma 209-216 xii CONTENTS. CHAPTER XIV. DISEASES OF THE VITREOUS HUMOR. PAGE. Diseases of the Vitreous Humor . ... 217-220 CHAPTER XV. CATARACT. Cataract. 221-247 CHAPTER XVI. SYMPATHETIC OPHTHALMIA — ENUCLEATION — ARTIFICIAL EVES. Sympathetic Ophthalmia — Euucleation — Artificial Eyes. . 248-260 CHAPTER XVII. Section I. Elementary Optics 261-274 Section II. The Causes and Effects of Insufficiencies of the Ocular Muscles — Strabismus 275-286 Section III. Methods of Detecting and Correcting Refrac- tive Errors — General Considerations for the Fitting of Glasses 287-318 CHAPTER XVIII. COLOR-BLINDNESS. Color - Blindness 319 CONTENTS. xiii CHAPTER XIX. EXTERNAL EXAMINATION OF THE EYE. PAGE. External Examiimtiou of the Eye 320-322 CPIAPTER XX. THERAPEUTICS OF THE EYE. Section I. Mydriatics — Myotics — Anaesthetics — Stimu- lants and Alteratives — Antiseptics 323-327 Section II. The Use and Abuse of Local Medication in Eye Affections 327-331 Section HI. Antisepsis — Bandages — General Considera- tions on Ophthalmic Therapeutics 332-334 CHAPTER XXI. RETINOSCOPY. Retinoscopy 335-339 CHAPTER XXII. Section I. Ophthalmoscopy 340-345 SETTion II. The Normal Fundus Oculi as seen with the Ophthalmoscope 345-351 CHAPTER XXIII. THE PERIMETER — PLACIDO'S DISC— OPHTHAL- MOMETRY. The Perimeter — Placido's Disc — Ophthalmometry 352-359 il^lustrations of instruments 360-364 Glossary 365-.398 A TEXT BOOK OF OPHTHALMOLCX}Y BY JOHN W. WRIGHT. OPHTHALMOLOGY. CHAPTER L SECTION I. CHE Eye is the organ of vision. Vision is the faculty of seeing. It is the process by which images of objects are made upon the retina and their impressions transferred to the brain. Ophthalmology is a treatise or a discourse upon the eye. For convenience of study, Ophthalmology is di- vided into the Anatomical, the Physiological, the Pathological and the Therapeutical. Anatomical Ophthalmology treats of the anatomy of the eye and its appendages. Physiological Ophthalmology treats of the functions of the eye and its appendages. Pathological Ophthalmology treats of the diseases of the eye and its appendages. Therapeutical Ophthalmology treats of the remedial agents used in the treatment of the diseases of the eye and its appendages. 2 text -book of ophthalmology. Anatomical and Physiological Oph- thalmology. The various diseases of the eye cannot be intel- ligently studied and appreciated without a knowl- edge of the parts which are in juxtaposition. Hence the anatomy of the Orbit, the place where the eye rests, is of significant importance. The Orbits are the cavities which contain the eyes. The orbits are four sided pyramidal bony cav- ities, with thie bases in front and the apices behind. Each orbit is composed of seven bones, viz. : superior maxillary, malar, frontal, palate, sphenoid, ethmoid, and lachrymal. For convenience of study the bones of each orbit may be arranged as follows: Bones of orbit. - Floor. Roof. Inner wall. Outer wall. Orbital plate of superior maxillar}'. Portion of ma- lar ; orbital process of palate bone. Orbital plate of frontal mainly ; at apex small portion of sphenoid. Mainly the ethmoid; lach- rymal ; sphenoid behind ; nasal process of superior maxillary in front. Sphenoid behind; malar in front. The openings or foramina of the orbit may be considered as foHows: SMALLER FORAMINA. Orbital Foramina. Optic. Sphenoidal. Splieno - maxillary. Lachrymal. Other foraminae. ) Communicates with the cra- ^ nial cavity. f Comnmnicates with the cra- * ui^l cavity. [ Communicates with the tem- poral, splieno - maxillary, and zygomatic fossae. / Lachrymal fossa with the *- nose. j The infra orbital, anterior -{ and posterior ethmoid, [^ and malar. The optic foraiiicit transmits the optic nerve and ophthalmic artery . The sphenoidal foramen (fissure) transmits the third and fourth ophthalmic divisions of the fifth and sixth nerves, and the ophthalmic vein. The splieno-maxUlary foramen (fissure) trans- mits the infra-orbital vessels and nerves, and the ascending branches from the spheno-palatine gang- lion, and superior maxillary nerve. The lachrymal foramen (groove) is occupied by the lachrymal sac and duct, through which the tears are transmitted to the nose. Smaller Foramina, hifra orhital foramen (groove) transmits infra orbita vessels and nerve. The malar foramen (sometimes two) transmits facial nerves. Anterior and posterior ethmoidal foramina transmit ethmoidal vessels and nasal nerve. 4 TEXT -BOOK OF OPHTHALMOLOGY. The orbit is lined by periosteum, continuous at the fissures and sutures with that of the bones of the face and the dura mater. The periosteum linini> the orbit forms a ten- (h^ious ring about the optic foramen; which gives origin to the ocular muscles. The orbital periosteum is covered with a layer of connective tissue and fat, Tipon which the e^^e rests. In the roof of the orbit are two depressions which require especial attention in the study of the eye: 1. The fovea trochhiris, at the inner angle for the pulley of the superior oblique muscle. 2. The fossae laelirymalls^ at the outer anterior angle for the lachrymal gland. SECTION 11. The Lids. The lids are the appendages of the eye. The lid from without, inward, is composed of hitequment, conneetlve tissue, orhicularis palpehral muscle, tarsal cartilage, meihomian glands, and con- junctiva. The integument, which is continuous with that of the face, becomes continuous with the conjunc- tiva at the border of the lids. The cilia are short stiff hairs placed in from THE LIDS. 5 two to four rows in the integument at the anterior border of the lids. The cilia protect the conjunctiva from dust and other foreign substances. A sehaceons follicle is a sack containing a gland which opens at each side of the follicle of each cilium. The functions of the cutaneous glands here are to moisten the cutaneous surface near the opening, and to soften the hairs. These sebaceous glands are sometimes called Zeissian glands. The orbicularis palpehrarum muscle surrounds the fissure between the lids, and is composed of pale thin fibres. It adheres closely to the integuiAent anteriorly b}- the connective tissue, but posteriorly glides over the tarsal cartilages. The opening formed by the edges of the lids is called the palpehral fissure. The tarsus (plural, — tarsi. The term tarsal cartilage is an improper application.) A semilunar framework of condensed connective tissue, giving firmness and shape to either eye lid. The tarsus in the upper lid is oval and is thick- est at its anterior edge. The tarsus in the lower lid is thinner and nar- rower than that of the upper lid and is of nearly uniform breadth throughout. The tarsi are firmly held in position by fibrous tissue internally to the tendo oculi, externally to the 6 TEXT -ROOK OF OPHTHALMOLOGY. malar boiu^, and above and below to the margin of the orbit, by the palpebral ligament The Mcihoniian glands, sometimes called palpe- bral glands, are sebaceous glands embodied in the under surface of each tarsus. The Meibomian glands number from 25 to 30 in the upper lid, and from 20 to 25 in the lower. Each gland consists of an excretory duct, with csecal appendages arranged along its sides. These ducts open on the free borders of the posterior lip of the eye lid. Lachrymal and Meibomian glands "^appcy) 1, 1, internal wall of the orbit , _>, 2, iiittinal portion of the orbicu- laris palpebrarum; 8, ;5, attachment of this muscle to the orbit : 1 orifice for the passage of the nasal artery ; '), muscle of Horner; 6, 6, posterior surface of the eyelids, with the Mei- bomian glands ; 7, 7, 8. 8, 9, 9, 10, lachrymal gland and ducts ;' 11, openings of the lachrymal ducts. Figure 1. The Meibomian glands are simply large seba- ceous glands whose function is to secrete the sebum, which lubricates the edges of the lids. This lubri- THE CONJUNCTIVA. 7 cation of the ed^es of the lids prevents tlie overflow of tears over their borders, and renders the palpebral fissnre TS'ater-tip:ht. The Conjunctiva. (ME:kiBRANA Conjunctiva.) The mncons membrane covering the inner sur- face of the eye lids and the outer surface of the eye ball. That part of the conjunctiva which covers the inner surface of the lids is known as the palpebral conjunctiva : the part covering the eye-ball, the bulhar or ocular conjunctiva. The conjunctival sac includes all that portion anterior to the eye and posterior to the lids. The ocular conjunctiva covers the anterior sur- face of the eye-ball, the anterior epithelium of the cornea being a continuation of it. Fornix conjunctiva is that portion of the con- junctiva at the point of reflection from the lid to the globe. The caruncula lachry malls is a small rounded projection at the inner angle of the eye, consisting of a little island of cutaneous tissue bearing fine hairs. The palpebral conjunctiva is thickest and most vascular, and is firmly adherent to the tarsus. The fornix conjunctiva is thin and loose. The scleral conjunctiva is thinner than the pal- pebral, and is loosely connected to the ball by epi- scleral tissue. 8 TEXT -BOOK OF OPHTHALMOLOGY. The corneal conjunctiva (almost entirely epi- thelial) is thinnest and very closely connected to the cornea. The edges of the lids are lubricated by the secre- tion of the Meibomian glands. The conjunctivae are moistened by the secretion from the lachr^^mal gland. The Lachrymal Apparatus. The Jachrj/nui] apparatus is composed of the lachrj/iiiaJ (/laud and its excrctorj/ (lachrymal) ducts, the lacJirj/nial canalicuU, the lachrjjmal sac, and nasal duct. The lachrymal gland consists of two portions: — a large superior, and a small inferior portion, situ- ated in a depression of the orbital plate, the fossa lachrymalis. The lachrymal ducts convey the secretion of the lachrymal gland under the conjunctiva and open at the fornix conjunctivae. They vary in number from seven to fourteen. The lachrymal canaliculi are situated at the inner angle of the margin of each lid, and unite before reaching the lachrymal sac. The laclirymal sac is the upper dilated portion of the passage which conveys the tears to the cavity of the nose. The nasal duct extends from the lachrymal sac to the inferior meatus of the nose. THE LACHRYMAL APPARATUS. 9 The punctn Jachrymalis are the small openings or mouths of the caualiculi. 18234 5 7 18 234 The left eye, with a portion of the eyelids REMOVED, TO EXHIBIT THE LACHRYMAL CANALS AND SAC. 1, lachrymal canals ; 2, commencement of these on the lachrymal papillae; 3. palpebral scutes; 4, edges of the eyelids; 5, lachrymal sac; 6, internal palpebral ligament ; 7, its point of division in front of the lach- rymal canals ; 8, branches of the ligament giving at- tachment to the fibres of the palpebral orbicular muscle. Figure 2. (After Sappey.) The physiological functions of the lachrymal apparatus are the secretion of the tears by the lach- rymal gland, their conveyance through the lach- rymal (excretory) ducts to the fornix conjunctivae, whence the eye is moistened; the secretion is then taken up by the puncta and passes through the canaliculi to the lachrymal sac, thence through the nasal duct and into the nose. The lachrymal secretion is a slightly alkaline solution, and serves to moisten the anterior portion of the eye. By the frequent closure of the lids the secretion is conveyed from the lachrymal gland to the lach- rvmal sac. 10 TEXT -BOOK OF OPHTHALMOLOGY. The eyelids are opened bv the contraction of the levator palpebnp superior is. The eyelids are closed by the contraction of the orbicularis palpebral and the relaxation of the leva- tor palpebral superioris. The levator palpebra superioris is supplied by the third nerve. The orbicularis palpebra is supplied by the facial nerve. The point of union betAveen the lids is called the palpebral commissure. The canthi are the angles formed by the junc- tion of the two lids. The outer part of the fissure is known as the outer canthus, and that of the inner, as the inner canthus. SECTION III. The Eye-ball. The eyeball is situated in the anterior part of the orbit to its outer side, and about equi-distant from its upper and lower walls. It rests upon a cushion of cellular tissue and receives protection in front by the eyelids. The eye is spheroidal in form with the segment of a smaller sphere projecting from its anterior surface. THE EYEBALL. 11 SUPERIOR RECTUS CHOROID OPTIC NERVE" CHOROlO -INFERIOR RtCTUS Figure 3. (After Flint.) The full size of the eye is not reached until about twenty 3- ears of age. The anterior pole of the eye is the geometric center of the cornea. The posterior pole or fundus of the eye is the geometric center of the back part of the globe. The optic axis is an imaginary line from pole to pole. This line is also the antero-posterior diam- eter of the eye. The equatorial plane is an imaginary plane through the center of the eye perpendicular to its axis, dividing the globe into the anterior and pos- terior hemispheres. 12 TEXT -BOOK OF OPHTHALMOLOGY. Meridional plmirs are imaginary planes coin- ciding with tlie axis. The weight of the eve is abont ninety-five grains. The anteroposterior diameter of the eye is about ninety-seven hundredths of an inch. Its vertical diameter is about ninety-one hundredths of an inch, and its transverse diameter is about ninety-three hundreths of an inch. The eyeball is composed of three tunics or coats, and from without inward are first, sclerotica and cornea; second, tunica vasculosa; third, the retina. The Sclerotica. The sclerotica is the tough, white, outer fibrous coat covering the whole of the eye except the an- terior portion occupied by the cornea. The sclerotic coat serves to give shape to the eye and protects its more delicate interior. The sclerotic is thickest at its posterior portion, and gradually becomes thinner as it approaches the cornea, where it again thickens at the sclero-corneal junction. In infancy the sclerotic is very thin, and more transparent than in the adult, as is evidenced by the bluish tint due to the choroid which lines its inner surface. Near the posterior axis of the eyeball is the lamina crihrosa, a sieve-like plate, consisting of many perforations of the sclerotic at this point, through THE SCLEROTICA. 13 which the optic nerve, after beiiij^ divided into many bundles of nerv(^ fibres, enters the eye. The canal of S chic nun or circular venous sinus is a congeries of blood vessels at the sclero corneal junction, and parallel to the corneal border, but entirely within the structure of the sclerotic. The circular venous sinus is the outlet by which the aqueous humor finds its way into the circulation. The cornea is the transparent part of the ex- ternal coat of the eyeball, and is situated in the anterior portion of the eye. The cornea projects beyond the curving surface of the sclerotic, and is therefore the segment of a smaller sphere than it (the sclerotic), and occupies about one-sixth of the surface of the eyeball. The cornea is about eleven mm. in its vertical diameter, and twelve mm. in its horizontal. The cornea is thicker at its rim than in the mid- dle, being about one and one-tenth to one and two- tenths mm. at the former and one mm. at the latter. The cornea consists of five layers from without, inwards, as follows: (1st) Epithelium ; (2nd) anterior elastic lamina, (Bowman's membrane); (3rd) the substantia propria, (cornea proper); (4tli) posterior elastic lamina,, (Des- cement's membrane); and (5th) the endothelium. The tissues of the cornea and sclerotic, at the junction of the two pass imperceptibly into each other. The cornea has no blood vessels, except for a 14 TEXT -BOOK OF OPHTHALMOLOGY. narrow space about its rim of about one and five- tenths mm., at which place it is supplied from the conjunctiva, the vessels of which run between the epithelium and the anterior elastic membrane and turn upon themselves in capillary loops. These vessels are from the episcleral branches of the an- terior ciliary arteries. The cornea is abundantly supplied with nerves, derived from the ciliary nerves, which enter from the sclerotica as medullary fibres, and divide, after their entrance into the cornea, into transparent (non- medullated) branches. The cornea receives its nourishment from a transparent liquid (the plasma) which circulates through the lymph spaces and channels of its sub- stance. Tunica Yasculosa. The tunica vasculosa or uveal tract, the second tunic of the eye, consists of the choroid, cUiarij body and iris. It lines the inner side of the sclerotica, and is perforated posteriorly by the optic nerve, and has a circular opening in front, the pupil. The choroidal and ciliar}' portion of the tunica vasculosa is adhered more or less firmly to the entire inner surface of the sclerotica; the iritic portion, excepting the corneal margin, is free, and its sur- faces are not adhered to any other part THE CHOROID. 15 SECTION IV. The Choroid. The choroid lic^s b(4ween the sclerotica and ret- ina, and extends from the optic nerve to the ciliary body. It is composed principally of blood vessels and dark brown pigment. 2iy±£^Uk Choroid coat of the i-ye Sappey). 1, optic nerve ; 2, '2, 2, 2, o, o, o, 4, sclerotic coat, divided and turned back to show the choroid ; 5, 5, 5, 5, the cornea divided into four portions and turned back ; 6, 6, canal of Schlemm ; 7, external surface of the choroid, tra- versed by the ciliary nerves and one of the long ciliary arteries; 8, central vessel, into which open the vasa vorticosa ; 9, 9, 10, 10, choroid zone ; 11, 11, ciliary nerves ; 12, long ciliary artery; 13, 13. 13, lo, anterior ciliary ar- teries; 14, iris"; 15,15, vascular circle of the iris ; 16, pupil. Figure 4. Although the choroid is very thin, (from 1|300 to 1|150 of an inch in thickness) it is composed of four distinct la^^ers from the sclerotic inward as follows: — lamina fusca, tunica vasculosa propria, memhrana cliorio-ca pillar is, lamina elastica. 16 TRXT-BOOK OF OPHTHALMOLOGY. 1st. Lamina fusca; a dark thin layer, com- posed of loose connective tissue containing dark pig- ment cells, from which it gets its color and name (fuscus, dark). Its principal office'seems to be to sur- round and protect the vessels and nerves passing forward to the ciliary body and iris. There is a lymph space between it (the lamina fusca) and tunica vasculosa propria, the supra- (Iioroidal space. 2nd. The tunica vasculosa propria, or the layer of larger choroidal arteries and veins. These arteries are derived from the short pos- terior ciliaries (ten or twelve in number) which enter the sclerotica around the optic nerve, and proceeding forward expand in this membrane into many inoscu- lating branches, some of which reach as far forward as the ciliary muscle, and there anastomose with the long and anterior ciliary arteries. The veins of the tunica vasculosa propria, the vena vorticosa, are much larger than the arteries and are situated exterior to them. 3rd. The mcmhrana cliorio-ca pillar is is composed of the minute vessels which connect the arteries (ar- teria ciliaris posteriores breves) with the veins (vena vorticosa). The functions of the chorio-capillaris are to con- vey the arterial blood to the venous system; to pro- vide nutrition to the eye; to regulate intra-ocular tension; to supply nutrition and warmth to the outer layers of the retina, and in conjunction with the cil- THE CILIARY BODY — THE CH^IARY MUSCLES. 17 iary process, to supply nourishment to the vil reous. 4th. The lamiiui chistica or lining membrane, a very thin hyaline membrane covering the inner surface of the nienibrana chorio-capillaris, the lay- ers of which are bound together by stroma, a fibrous network in whose meshes are pigment-cells more or less abundant in light eyes. The Cn.LARY Body. The ciliary body is that portion of the tunica vasculosa which lies between the choroid and iris. It is continuous with both and is about one-fourth of an inch in width. The ciliary body is composed of the ciliary muscles and the ciliary processes. Tpie Ciliary Muscles. The nmscles of the ciliary bod}^ are radiaiiug and circular. The radiating fibres of the ciliary muscles are confined to the outer portion of the cil- iary body, and arise tendenously from the sclero- corneal junction, the posterior elastic lamina and from the ligamentum pectinatum iridis, and are di- rected backwards and inwards where they tc^rminate in the choroid. The inner portion of the ciliary muscle consists of bundles of fibres which pursue a circular course and are hence termed the circular fibres of the cil- iary muscle. The circular fibres of the ciliary muscle occupy 18 TEXT -BOOK OF OPHTHALMOLOGY. that portion of the ciliary body near its junction with the iris. The ciliary muscles are much devel- oped in hyperopia. Ciliary muscle; magnified lo diayneters (Sappey). 1 1, crystalline lens ; 2, hyaloid membrane ; 3, zone of Zinn ; -1, iris ; 5, 5, one of the cil- 'iary processes ; 6. 6, radiating fibres of the ciliary muscle ; 7, section of the cir- cular portion of the ciliary muscle ; 8, venous plexus of the ciliary process ; V), lOi sclerotic coat ; 11, 12, cornea ; 13, epithelial layer of the cornea ; 14, membrane of Descemet ; 15, ligamentnm iridis pectinatum; 16, epithelium of the membrane of Descemet ; 17, union of the sclerotic coat with the cornea : 18, section of the canal of Schlemm. Figure 5. In myopia they are less deveh)ped and are some- times indeed almost entirely wanting. The above conditions of tlie ciliary muscle are very readily accounted for when we consider that the circular fibres are the ones whose function it is to provide for accommodation, and as accommoda- THE CILIARY PROCESSES. 19 tion is but little omployed in myopia, tbey arc not properly developed, while the opposite condition ex- ists in hyperopia, the circular fibres being constantly called into action at every effort to see, become ex- cessively developed. The CiEiARY Processes. The ciliary processes are formed by folds of the choroid at its anterior margin, covering the inner surface of the ciliary body and forming a circle be- hind the iris around the margin of the lens. Each one of these folds is called a process. The ciliary processes number about seventy- two, and are of variable size, the larger of which are about one-tenth of an inch in length. The smaller processes are superimposed between the larger ones, but not in regular order. The ciliary processes are deepest and thickest at their fore part and gradually taper into the cho- roid behind. Their anterior extremities are rounded and free, and are suspended in the aqueous humor in a circle behind the outer border of the iris. Within the folds of the ciliary processes are re- ceived corresponding folds of the thick membrane called the zone of Zinn. This membrane is contin- uous with the anterior portion of the hyaloid mem- brane. The ciliary body is richly supplied with nerves from the long and short ciliary, and blood vessels principally from the long ciliary arteries; hence that 20 TEXT -BOOK OF OPHTHALMOLOGY. part of the sclerotic immediately exterior to it is called the ^'danger zone/' because any affection or injury of this structure is marked by extreme ten- derness in this region of the eye. The '^danger zonc^^ commences at the junction of the sclerotic and the cornea and extends back- wards one-fourth of an inch. SECTION V. Ttik Jkis. The iris is a membranous disk continuous with the ciliary bod}^ and choroid with a central opening the pupil. It is held in its position through the in- tervention of the ligamentum pectinatum iridis, by which its greater circumference is attached to the sclero-corneal junction. The iris also receives sup- port from the lens, whose anterior surface is rested upon by the posterior surface of its pupillary border, thus pushing that part of the iris forward, causing it to be slightly convex in front. The iris originates from the anterior surface of the ciliary body, being formed principally by the branches of the long ciliary arteries, which divide into two branches at the ciliary muscle on each side of the eye, and run in a direction concentric with the margin of the cornea, and uniting with the vessels of the opposite side form the circuhis artei'iosus iridis major. THE IRIS. 21 From this extend the radial arteries to near the pupinary border, forming the circHlns arteriosus iridis minor. The choroidea and iris. 1, ciliary arteries situated at the sides of the optic nerve ; 2, the long ciliary arteries ; 3, the same after having- pierced the sclerotica > 4, 5, the main divisions of the same vessels ; 6, the ciliarj'^ muscle ; 7, the anterior cil- iary arteries ; 8, the short ciliary arteries to the choroidea ; 9, the iris supplied by the long and anterior ciliary arteries ; 10, the pupil. Veins of the choroidea and iris. 1, sclerotica ; 2, choroidea ; 3, ciliary muscle, of which a portion has been removed to exhibit the ciliarj^ processes; 4, 5, the iris ; 6, pupil ; 7, 8, trunks of the choroid veins ; 9, 10, vorticose vessels ; 11, their conjunction with the veins of the ciliary processes; 12, anastomosis between the groups of vorticose vessels. Figure 6. After vSappey.) The vessels forming the iris are surrounded by a loose mesh-work of pigmented cells which fill the interspaces near the pupillary border; embedded in the stroma is the sphincter iridis, the contraction of which closes the pupil. If the lens is absent, then the iris vibrates with the movement of the eve-ball. This condition of the 22 TEXT-1K)()K OF OPHTIiALMOLOGY. iris is known as iridodoncsis. and is caused by the loss of support which the iris receives from the lens. The iris is divided into two zones: the ciJianj zone and the piipillari/ zo)ie. The ciliary zone extends from the peripheral border of the iris to the circiilus minor. The pupillary zone extends from the circulns minor to the pupillary border of the iris. These zones can best be distinguished in the blue eyes of children, where the pupillary margin is lined by a narrow black fringe. They are also observed in those who are affected with cataract, where the Avhite background of the opaque lens contrasts with the black fringe of the iris, thereby making them appear prominent. The anterior surface of the iris is lined with a membrane continuous with the endothelium lining the posterior surface of the cornea. There are crypts or depressions in the iris which communi- cate with its tissues and place them (the tissue- spaces) into free communication with the anterior chamber of the eye. These crypts are not covered w^ith endothelium. The posterior surface of the iris is covered by the posterior lining membrane and the retinal pigment layer. The diameter of the iris is about 12 mm. (one- half inch). The pupil is subject to variations in size, ordi- narily from 3 mm. to 5 mm. (^ to 1-5 inch). THE IRIS. 23 The color of the iris depends upon the amount and tints of the particles contained in its pigment cells, and varies in different individuals. Segment of the choroidea and iris, SEEN ON ITS INNER SURFACE, magnified four diameters. 1, ciliary processes ; 2, their free extremities behind the iris ; 3, 4, commence- ment of the processes ; 5, intervals of the processes ; 6, veins of the ciliary processes! 7, posterior margin of the ciliary body ; 8' choroidea with its veins ; 9, iris ; 10, its outer border; 11, the pupillary border ; 12, radiat- ing fibres of the iris ; 13, circular fibres. Figure 7. (After Sappey.) The color of the irides as a rule are the same, but there are instances in which there are congenital differences although they maj^ be perfecth^ healthy. The iris by the action of the pupil in dilating and contracting, regulates the amount of light which enters the eve. 24 tkxt-book of ophthalmology. The Pupil. The pupil is the aperture in the iris for the trans- mission of rays of lij»ht. The pupil is normally eccentric, that is, slightly below and to the inner side. This condition is not noticeable without minute examination of the eye. Corcctopia is that condition in which the pupil is noticeably eccentric Polj/coria is that condition in which there is a multiplicity of pupils (that is, more than one). A natural pupil is one which exists at birth. An artificial pupil is one that has been made by art. There is no standard size of the normal pupil, as so many contingencies exist even in health, which tend to change it ; neither are there established meaais by which to record the exact measurement of the pupil. The pupil in normal conditions varies in diam- eter from two mm. to six mm., the average diameter being- about four mm. The pupil is larger in children than in adults. In old age it becomes very small. The pupil in the normal eye should be round and promptly contract and dilate to the effects of light and shade. It also contracts in the effort to accommodate and converge, that is to observe a near point, and dilates when the eye is adjusted for dis- tant vision. THE PUPIL. 25 If one eve be shaded and the other exposed to a lioht, the pupil of the shaded eye acts in harmony with the other; this is termed the consensual action of the pupils. The pupils of both eves should be of uniform size under the same illumination. Mi/driasis is a morbid and excessive dilation of the piipil. Mi/driasis may be paralytic or spastic. Paralytic mydriasis is produced by paralysis of the sphincter pupilla or its supplying nerve. Spastic mydriasis is produced by spasm of the dilator fibres of the iris, or stimulation of the sym- pathetic. Myosis is an abnormal or excessive contraction of the pupil. Myosis is paralytic or spastic. Paralytic myosis is due to paralysis of the dila- tor fibres of the iris. Spastic myosis is due to spasm of the sphincter pupilla. There is also a contraction of the pupil known as spinal myosis which is regarded as a significant symptom in spinal disease, such as locomotor ataxia. Myopes as a rule have large pupils and hyper- opes small. Hip pus is a spontaneous, rapid and spasmodic dilation and contraction of the pupil. This condi- tion is often observed in hysteria, mania, and other nervous affections. Its cause is obscure. 26 TEXT -BOOK OF OPHTHALMOLOGY. A nnjdtHatic is an agent which produces dila- tation of the pupil. The principal mydriatics are atropine, dubois- ine, hyoscjamin and cocaine. A myotic is an agent which causes contraction of the pupil. The principal myotics are eserine, pilocarpine, and morphine. Mydriasis or the dilatation of the pupil occurs in glaucoma, atropli}^ of the optic nerve, (although not constant) paralysis of the oculomotor nerves, paralysis of the nerves of the iris due to inflammation or increase of tension. Myosis or contraction of the pupil occurs in hy- pera^mia or inflammation of the iris, in the early stajie of all inflammatory affections of the brain and meninges, in diseases of the spinal chord. Exclusion of the pupil is that condition in which the entire border of the iris is adherent to the cap- sule of the lens so that no fluid can pass through the pupillary space. In occlusion of the pupil there is adhesion of the entire border of the iris to the lens capsule, but the pupillary space is filled with plastic lymph. Wliat is known as the Argyll Robertson pupil is that condition in which there is absence of reaction to light, although there is contraction of the already small pupil for accommodation and convergence. The pupil in many cases reacts to light when there is no perception of light. THE RETINA. 2T Li.i»lit may be thrown into an eye whose pupil for some cause may not react, when its fellow will respond as promptly as if the light had been applied to the latter. Irregularities in the dilation of a pupil under the effects of a mydriatic indicate the existence of synechia. An inactive and dilated pupil does not always indicate a diseased condition of the retina. SECTION YI. The Retina. The retina is the third or inner tunic of the eye. The retina is a delicate transparent membrane formed from the fibres of the optic nerve, which are spread out in every direction from the entrance of the optic nerve to the ora serrata. The retina is composed of two kinds of tissue, the nervous tissue and the supporting tissue, and these tissues assist in forming all the layers of the retina. The retina is attached at two points only, at the optic nerve entrance, and at its anterior border, the ora serrata. The retina is not attached to the chor- oid, but simply lies on it. In viewing the normal retina with the opthal- moscope, two points are particularly prominent, the optic disk and the macula lutea. 28 TEXT -BOOK OF OPHTHALMOLOGY. The optic disK' is the head of the optic nerve, and marks its entrance into the gh>be. The macula lutca is a thinning of the retina, and is marked by a central depression, the fovea centralis. It is about 1-G mm. in diameter. The microscopical examination of the retina demonstrates that it is composed, from within the globe outward, of the following la^^ers: 1. Membrana limitans interna. 2. Fibrous la^er. 3. Vesicular la^er. ^ 4. Inner molecular layer. 5. Inner nuclear layer. 6. Outer molecular layer. 7. Outer nuclear layer. 8. External limiting membrane. 9. Jacob's membrane or rods and cones. _ 10. Pigmentary layer. 1. Mernhrana I'miitajis interna, or the inter- nal limiting membrane, is a thin transparent and imperfect membrane, said to be formed from the retinal connective tissue. It lies in contact with the hyaloid membrane of the vitreous humor. Its ex- istence is considered doubtful by some histologists. 2. The flhrous laijcr is formed by fibres of the optic nerve in their course to the ganglion cells. 3. The vesicular layer is a single layer of large ganglion cells. Their structures are similar to those of the nerve centers. 4. The inner molecular layer is made up of THE RETINA. 29 fine fibres mingled with the processes of the ganglion cells. 5. Tlio 'ninrr nuvJvar lai/cr consists of two kinds of cellular elements, and two kinds of fibres. This layer is also known as the inner granular layer. G. The outer moJvcuJar hnjcr resembles the inner molecular layer, but contains branched stellate cells, supposed to be ganglion cells. 7. The ouiiv imclcar hujvr consists of rod-gran- ules and cone-granules and connective tissue ele- ments. 8. The external Ilnnting menihrane is formed of retinal connective tissue, the terminal extremities of the fibres of Miiller. 9. JaeciWs memhrane or rods and cones is com- posed of rods arranged perpendicularly to its surface, and cones with apices directed towards the choroid. This is the most important part of the retina, being the percipient layer. 10. The pigmoitarji lai/er consists of a single layer of hexagonal, nucleated cells. This layer was formerly considered part of the choroid. The vascular suppl}^ of the retina is derived from the arteria centralis, with the exception of a slif>iit anostomosis with the choroidal vessels at the optic disk. The lymphatics of the retina exist around the vessels in the form of peri-vascular hanph-spaces. The r^ods and crjnes are the percipient organs of the retina, and are connected bv nerve-fibrils with 30 TEXT -BOOK OF OPHTHALMOLOGY. the layer of nerve-fibres which convey the visnal im- pulses throu<;h the optic nerve to the brain. The point of most acute vision in the retina is the macula lutca, and for distinct vision the rays of light from an object must focus upon this point. The objects of interest as seen in the retina of a normal eye through the ophthalmoscope, are the optic disk, the macula lutea and the retinal vessels. A description of these parts will be fully given in the chapter on the ophthalmoscope. The Optic Nerve. Op(/c trai ts commissure and nerves [ Hirschfeld 1, infundibulum; corpjis cinereum ; 3, corpora aloicantia ; 4, cerebral peduncle ; 5. pons Varolii ; <>, optic tracts and nerves, decussating at the commissure, or chiasm ; 7, mo- tor oculi communis; 8, patheti- cus; 9, fifth nerve; 10, motor oculi externus; 11, facial nerve; 12, auditory ner\'e ; l"., nerve of Wrisberg ; 14, glosso - pharyngeal nerve; 15, pneumogastric ; 16, spinal accessory; 1', sublingual nerve. * Figure 8. THE OPTIC NERVE. 81 The optic ncnws arise from the optic commis- sure, and pass forward aud outward to the two optic foramina. The optic nerves are formed at the commissure by a decussation of the fibres of the optic tracts. The optic tracts are formed by two roots, — the external and the internal. The external root takes its origin from three centers of gray matter, viz. the optic thalamus, the external geniculate body, and the anterior tubercles of the corpora quadrigemina. The internal root arises from two centers of gray matter, viz. from the internal geniculate body and the posterior tubercles of the corpora quadrigemina. These centers of gray matter which give origin to the optic tracts are connected to the cerebral cor- tex by a system of fibres known as the cortico optic radiating fasciculi and constitutes the most pos- terior part of the optic thalamus. After the formation of the optic tract by the union of the external and internal roots, it passes forward along the posterior inferior surface of the optic thalamus, crosses the cms cerebri, traverses the side of the tuber cinerium, and in front of the infundibulum unites with the optic tract of the other side to form the optic commissure. In the optic commissure the fibres of each optic tract undergo semi-decussation, that is, the outer fibres of each tract are continued into the nerve of the same side. The central fibres of each tract are 32 TEXT -BOOK OF OPHTHALMOLOGY. continued into the optic nerve of the opposite side, decussating in the commissure and extend to the optic papilla or disk. From its origin, the optic commissure, each optic nerve passes forward and outward to the optic fora- men of its side. The optic nerve is divided into three portions from within outward as follows: 1st. The intra-cranialy which part is included between the chiasm and the optic foramen. 2d. The orbital, which includes that portion between the optic foramen and the e^^eball. 3d. The Infra-ocular, which is found within the sclerotic and is the termination of the nerve. The intra-cranial portion of the optic nerve is enclosed in a sheath derived from the arachnoid. As the optic nerve passes through the optic fora- men it receives an aditional covering from the dura mater which covers that portion of the nerve witliin the foramen. As the optic nerve enters the orbit, this sheath from the dura mater subdivides into two layers, one portion of which is continuous with the periosteum of the orbit, and the other with the arachnoid sur- rounds the optic nerve as far as the sclerotic. As the optic nerve enters the eyeball it becomes constricted in its diameter and looses its coverings from the arachnoid and dura mater, which become fused with the sclerotic coat. The coarser interstitial connective tissue of the THE OPTIC NERVE. 33 nerve is intercepted by the lamina eribosa, and only the nerve-tubules and the blood vessels and some fine connective tissue elements are permitted to pass through into the interior of the globe. Immediately anterior to the sclerotic foramen is the choroidal foramen, the margin of which is marked at parts of its entire circumference with black pigment. The fibres of the optic nerve pass through these two foramina and immediate!}^ curve boldly round the margin of the choroidal foramen and spread out in all directions to form the anterior layer of the retina. The optic nerve does not enter the eye at its posterior pole, but a little to the nasal side of it. Just before the optic nerve enters the globe, it is perforated by a small artery, the arteria centralis retina, which traverses its interior in a canal of fib- rous tissue, and supplies the inner surface of the retina. This artery is accompanied by correspond- ing veins. The optic nerve is about four mm. (1-6 inch) in diameter and 28 mm. (1:^ inches) in length in its orbital portion. The optic nerve is supplied by blood vessels from the ophthalmic artery. The special and perhaps only function of the optic nerve is to convey impressions of sight to the cerebrum. The optic nerve is not endow^ed with general sensibility and is therefore insensible to ordinary impressions. 34 TEXT -BOOK OF OPHTHALMOLOGY. a V '$:M temporal m sdsan se ^ ^ n se P ar^,j, B Head of the Optic Nerve. Ophthalmoscopic View. — Somewhat to the inner .side of the center of the papilla the central artery arises from below, and to the temporal side of it rises the central vein. To the temporal side of the latter lies the small physiological excavation with the gray stippling of the lamina cribrosa. The papilla is encircled by the light scleral ring (be- tween c and d) and the dark chorioidal ring at d. Longitudinal Section through the Head of the Optic Nerve. — Magnified 14x1. The trunk of the nerve up to the lamina cribrosa has a dark color because it consists of medullated nerve-fibers, «, which have been stained black by Weigert's method. The clear interspaces, se separating them, correspond to the septa composed of connective tissue. The nerve- trunk is enveloped by the sheath of pia mater, /, the arachnoid sheath, ar. and the sheath of dura mater, du. There is a free interspace remaining be- tween the -sheaths, consisting of the subdural space, sd, and the subarachnoid space, sa. Both spaces have a blind ending in the sclera at e. The sheath of dura mater passes into the external layers, sa, of the sclera, the sheath of pia mater into the internal layers, si, which latter extend as the lamina cribrosa transversely across the course of the optic nerve. The nerve is represented in front of the lamina as of light color, because here it consists of non-medullated and hence transparent nerve-fibres. The optic nerve spreads out upon the retina r, in such a wav that in its center there is produced a fininel-shaped depression, the vascular funnel, b, on whose inner wall the central artery, a, and the cen- tral vein, V, ascend. The chorioid,rA, shows a transverse section of its numerous blood- vessels, and toward the retina a dark line, the pigment epithelium is next the margin of the foramen for the optic nerve and corresponding to the situation of the chorioidal ring the chorioid is more darkly pigmented, ci is a posterior short ciliary artery which reaches the chorioid through the sclera. Between the edge of the chorioid, d. and the margin of the head of the optic nerve, <:, there is a narrow interspace in which the sclera lies exf>osed, and which corresponds to the scleral ring visible by the ophthalmoscope. Figure 9 A. & B. (Figure and description by Fuchs.) OPTIC DISK. 35 OrTic Disk. The papilla nervi optiei or optic disk is formed by the radiating fibres of the optic nerve immediately after their passage through the openings in the scle- rotic and choroid. The central artery of the retina emerges from the optic nerve rather to the inner side of the disk where it bifurcates, one branch of v^^hich passes ver- tically upwards and the other downwards to the retina. The central vein accompanies the artery and is easily recognized by its darker color and larger size. The optic disk, along its margin, is frequently marked by patches of black pigment, which repre- sent spots of choroid. This is the margin of the choroidal foramina, therefore a black crescent lying against one side of the papilla or disk, or a black line entirely surrounding it, is a common physiological phenomenon. The optic disk, therefore, is all that portion in- cluded within the margins of the choroidal foramen. Internal to the choroidal foramen and at the edge of the disk is a whitish ring, the sclerotic ring, caused by the choroidal foramen being somewhat larger than the optic foramen, so that the edge of the sclerotic is seen as a white band through the transparent fibres. The sclerotic ring is not always complete and is more marked at the outer side of 36 TEXT -BOOK OF OPHTHALMOLOGY. the disk owing to a thinning of the fibres of the optic nerve in that region. The optic disk is usually round or oval in shape, although it may be very irregular in outline. It is about 1-5 mm. in its transverse diameter. There is a depression near the center of the optic disk formed by the manner in which the nerve fibres change their direction in their passage to different portions of the retina. This depression is known as the phiiHiohxilcdl e.rca ratio)! or cup. The optic disk is pierced in the center of the physiological excavation by the central retinal artery and vein. The capillaries of the optic disk are supplied from three sources, viz. the short ciliary arteries of the choroid, the central artery of the retina, and the arterial twigs of the pial sheath. The optic disk- is really the head of the optic nerve, and is the only portion of the retina where the sense of vision is wanting, and is therefore called the hruul spot. SECTION YII. The Media of the Eye. The term mcd'non in optics signifies any sub- stance that will transmit light. The media in ophthalmology are those parts of the eye which transmit the rays of light in the func- OPTIC DISK. 37 tion of seeing. They are the cornea, the aqueous humor, crystalline lens and the vitreous humor. The cornea is the clear transparent anterior por- tion of the sclerotic. The aqueous humor is the colorless transparent liquid occupying that portion of the cavity of the eye lying between the cornea and crystalline lens. The space thus occupied is called the aqueous chamber. Vertical section antero - posteriorly of the eyeball. 1, optic nerve ; 2, sclerotica; 3, its posterior thicker portion ; 4, sheath of the optic nerve continuous with the sclerotica; 5, the nerve within the sheath ; 6, insertion of the recti muscles into the sclerotica ; 7, 8, su- perior and inferior recti muscles ; 9, cornea ; 10, its conjunctival surface ; 11, entocornea ; 12, 13, bevelled edge of the cornea fitting into the sclerotica ; 14, circular sinus of the iris ; 15, choroidea ; 16, the anterior portion, constituting the ciliar\^ body ; 17, the ciliary muscle ; 18, the ciliary processes ; 19, retina ; 20, its origin ; 21, the ora ; 22, central retinal artery ; 23, vitreous humor ; 24, 25, 26, hyaloid tunic ; 27, suspensory ligament of the crystalline lens ; 28, 29, iris ; 30, pupil ; 31, posterior chamber, and 32, anterior chamber occupied by the aqueous humor. Figure 10. (After Sappey.) The iris separates this chamber into two parts, the anterior chamber and the posterior chamber. The two chambers communicate with each other through the pupil. 38 TEXT -BOOK OF OPHTHALMOLOGY. The aqueous humor is faintly alkaline, and has a specific gravity of about 1005. The aqueous humor is rapidly reproduced after it has been evacuated, as occurs frequently in acci- dents or operations upon the eye. The aqueous humor is secreted by the ciliary processes, and the posterior surface of the iris. The aqueous chamber has its exit at the angle between the iris and cornea, through the spaces of Fontana (the meshwork of the ligamentum pectina- tum) into the canal of Schlemm, thence through a system of valves into a plexus of veins where it is convej^ed to the choroidal veins. The aqueous chamber together with the canal of Petit and the canal of Schlemm can properly be regarded as lymph spaces, and the aqueous humor as the lymph occupying these spaces. The crystalline lens is a lens-shaped body oc- cupying the space in the antero-posterior diameter of the eye, between the aqueous humor and the crys- talline humor. It is perfectly transparent and very elastic. The crystalline lens is a nonvascular agglome- ration of transparent fibrils, arranged in radiating sectors, and enclosed in a fibrous capsule (the lens capsule), situated in the hyaloid fossa of the vit- reous humor, and held in position by the annular sus- pensory ligament, (zonule of Zinn). The crystalline lens after the age of twenty-five years becomes hardened in the center, which por- OPTIC DISK. 39 tion is termed the nucleus, which is surrounded by the non-sclerosed portion or cortex. The crystalline lens, owing to its shape, is the most refracting of the media of the eye, its action being analogous to that of the convex lenses of opti- cal instruments. It causes the rays of light passing- through it to focus, .in the normal eye, upon the retina. Owing to the action of the ciliary muscles the crystalline lens varies in its convexities, owing to the distance at which the gaze is directed. When the object viewed is near, the lens is more convex; \vhen it is at a distance, it is less convex. The crystalline lens in the adult is about 8.5 mm. in its transverse diameter and about 6.5 mm. in its antero-posterior diameter. At about forty-five years of age the crystalline lens loses so much of its elasticity and becomes so hard that a convex lens must be placed before the eye to enable it to discern near objects plainly. The absence of the crystalline lens is known as aphakia. This condition has never been discovered as a congenital defect, but as the result of an acci- dent or surgical operation. The vitreous humor is the transparent gelatin- ous mass which occupies the posterior cavity of the eye. The vitreous humor is not a secreted fluid like the aqueous, but an embryonic product which is formed in the vitreous chamber at a very early 40 TKXT-BOOK OF OPHTHALMOLOGY. period of fo'tal lifV. When a portion of it is lost, it therefore is not re])ro(hu'ed, but its place is filled bj lyni])li, which does not canse appreciable loss of vision. The vitreons hnnior is surrounded by a trans- parent capsule, the Jn/aloid nicinhnnic. The anterior portion of the vitreous humor has a deep depression, the hj/aloid fo.s.sa, in which the posterior surface of the crystalline lens rests. The vitreous humor is traversed in its antero- posterior diameter by a canal, the canaJis lu/aloideus, which has its orih the anterior lymph passages, the anterior system is the most important factor in many affections of the eye. lyYMPH - Passages of the Eye. Schematic. S, Schlemm's canal ; c, anterior ciliary veins : h. h\aloid canal ; p, perichorioidal space, which communicates by means of the vence vorticosse, ?■, with Tenon's space ; f, t; s, supravaginal space; t, intervaginal space; e, ey , continuation of Tenon's capsule UfKin the tendons of the ocular muscles lateral invagination). Figure 12. After Fuchs. ) A thorough study of the lymphatic system of the eye should be made, for upon all theories of intra- ocular pressure it has important value. The Musclp^s of the Eye. The eyeball is moved in various directions by the actions of its muscles. 46 TEXT -BOOK OF OPHTHALMOLOGY. The muscles which contribute to its movements are the external rectus, the internal rectus, the superior rectus, the inferior rectus, the superior oblique and the inferior ohliigue. These muscles are called the extrin- sic muscles of the eye. Muscles of the eye. 1, the palpebral elevator; 2, the trochlear muscle; 3, the pulley through which the tendon of insertion pla3'S. 4, superior rectus muscle ; 5, inferior rectus muscle ; 6, external rectus muscle ; 7, 8, its two points of origin ; 9, interval through which pass the oculo-motor and abducent ner\'es ; 10, inferior oblique muscle ; 11, optic nerve ; 12, cut surface of the malar process of the superior maxillary bone ; 13, the nasal notch. A, the eyeball. Figure 13. (After Morton.; The external rectus muscle arises from two heads, the upper one from the outer margin of the optic foramen, and its lower head from the lower margin of the sphenoidal fissure, and is inserted into the sclerotic coat about 6 mm. from the margin of the cornea. It is the longest of the recti muscles. The internal rectus arises with the inferior rec- tus from a common tendon from the lower and inner THE MUvSCLES OF THE EYE. 47 circumference of the optic foramen, and is inserted into the sclerotic abont G mm. from the margin of the cornea. This muscle is tlie broadest and strong- est of the recti. The superior' rectus muscle arises from the up- per margin of the optic foramen, and from the fibrous sheath of the optic nerve, and is inserted into the sclerotic about 6 mm. from the margin of the cor- nea. This muscle is the thinnest and narrowest of the recti. The inferior rectus muscle arises by a common tendon with the internal rectus, and is inserted into the sclerotic at about 6mm. from its corneal margin, as the other recti muscles. The superior ohlique arises from the inner mar- gin of the optical foramen and terminates in a rounded tendon which glides through a cartilaginous pulley beneath the internal angular process of the frontal bone, then it passes under the superior rec- tus and is inserted into the sclerotic midway between the margin of the cornea and the optic nerve, be- tween the superior and the external recti muscles. The inferior ohlique arises from the orbital plate of the superior maxillary and is inserted into the sclerotic between the superior and external recti. The varied movements of the eye are accom- plished by these muscles, for the performance of which they are arranged in three pairs, each pair consisting of two muscles, the actions of which are antau'onistic. 48 ' TEXT -BOOK OF OPHTHALMOLOGY. The first pair is the rectus internus and rectus externus, the former rotating the eye inward and the latter outward. The second pair is the rectus superior and the rectus inferior, the rectus superior rotating the eye upward and tlie rectus inferior downwards. The third pair is the superior oblique and the inferior oblique, the former inclines the vertical mo- tion of the eye inward (wheel motion inw^ard) and the latter inclines the vertical meridian outward (wheel motion outward). Nerve Supply of the Orbital Muscles. The external rectus is supplied by the sixth cranial or abducens. The internal rectus muscle is supplied by the third cranial or motor oculi. The superior rectus is supplied by the third cranial or motor oculi. The inferior rectus is supplied by the third cra- nial or motor oculi. The superior oblique is supplied by the fourth cranial or patheticus. The inferior oblique is supplied by the third cranial or motor oculi. The Blood Vessels of the Ocular Muscles. The muscles are all supplied by branches from the ophthalmic artery. The veins of the muscles empty into the oph- thalmic and facial. DISEASES OF THE ORBIT. 49 CHAPTER n. Diseases of the Orbit. CHE following may be enumerated as the dis- eases of the orbit: Periostitis, necrosis^ cellulitis^ tumors. . Periostitis of the orbit may be aciiie or chronic. Acute periostitis may be local or diffused. Acute periostitis is characterized by pain, swell- ing of the lids, inflammation of the conjunctiva, slight protrusion of the ball, and tenderness over the seat of the affection if it is localized. The rim of the orbit is attacked with special fre- quency on account of its exposure to traumatism. If the inflammation is diffused, the pain, swell- ing of the lids and conjunctival inflammation is much more pronounced. In the severe cases there is an increase of temperature, and occasionally de- lirium. As acute periostitis of the orbit has many symp- toms in common with orbital cellulitis, a differential diagnosis is often difficult, especially as the latter generally accompanies the former. The absence of tenderness on pressure upon the margin of the orbit is considered by many oculists as indicative of absence of periostitis. There is not so much tenderness and swelling 50 TEXT -BOOK OF OPHTHALMOLOGY. of the lids or conjimctival irritation in periostitis as in cellulitis. In acute periostitis there is always a tendency to suppuration, but there is no tendency to suppura- tion in chronic periostitis. Chronic periostitis of the orbit is accompanied by pain in and about the orbit with tenderness on pressure of the ball, but swelling of the lids, che- mosis of the conjunctiva and the exophthalnius which are present in the acute variety are usually absent in the chronic. Periostitis of the orbit is usually due to some traumatism, as blows or penetrating wounds near the margin. The chronic variety is usually the result of syphilis or 'rheumatism. Treatment, in the acute variety, consists in the application of fomentations, as hot as can pos- sibly be borne, in order to hasten resolution and absorption. If impossible, then evacuate the pus at the earliest possible moment. In the chronic variety we must depend on con- stitutional remedies. ^Necrosis of the Bones of the Orbit. As necrosis of the bones of the orbit usually follows periostitis, the affection rarely occurs pri- marily. We have therefore in this disease all of the accompanying symptoms, as pain and swelling of the lids and conjunctiva. . NECROSIS OF run RONES OF THE ORBIT. 51 As in periostitis, the rim of tlie orbit is usually the seat of tlie affection. Accompanying the pain is a circumscribed swelling, indurated at first, followed usually by softening, then perforation and evacuation. Ab- sorption and resolution rarely, though occasionally, take place. After evacuation the sound, if intro- duced into the cavity, will come in contact with rough bone. When the necrosis is situated deep in the orbit, there is increased inflammatory action. The lids become very swollen, the conjunctiva chemotic, and the ball protruded to an exceedingly disfiguring ex- tent. The pain is very severe and usually worse at night. The cellular tissue cannot remain intact in periostitis and necrosis, but is more or less impli- cated and often becomes so seriously involved that the eye is sacrificed. The causes of necrosis, like that of its prede- cessor, periostitis, are usually wounds and injuries of the orbit (mostly at its rim), rheumatism and s^'philis. Occurring in children, it is usually of scrofulous origin. If the rim of the orbit is alone affected, the prognosis is usually good. If however the necrosis is deep in the orbit, the prognosis is grave, because of the extension of the inflammation to the meninges of the brain, the in- jury to the optic nerve, and the involvement of the eye in the general inflammatory condition. 52 TEXT -BOOK OF OPHTHALMOLOGY. In the treatment at the incipiency of the affec- tion, no matter what the cause, warm fomentations are indicated. The applications of tincture of iodine, mercurial ointment and other medicines said to have deob- struent properties are useless. If resolution and absorption cannot be effected, the escape of pus must be hastened by incision with a narrow scalpel, piercing the conjunctiA'a as near the fornix as possible, and following the orbital wall to the abcess. The wound should be thoroughly cleansed with antiseptic solutions — preferably the bichloride of mercury solution, l-5000th. If the patient is rheumatic or has had syphilis, constitutional treatment is necessary. My prefer- ance is the iodide of potassium. In the adult from 30 to 60 drops of the saturated solution, in three or four tablespoonfuls of milk, before meals. Orbital Cellulitis. The cellular and fatty tissue forming the cush- ion for the eyeball is liable to inflammation. The symptoms accompanying orbital cellulitis are fever, pain, oedema of the lids, inflammation of the conjunctiva, frequently chemosis and more or less protrusion of the eyeball. The protrusion of the eye is frequently so great that the lids will not cover the entire ball, and the movements of the globe are limited, often to a con- siderable extent. TUMORS OF THE ORBIT. 53 If pressure is made between the mar^jin of the orbit and the ball, the tumor may be located, which is generally at the outer and upper angle of the orbit. The tumor gradually increases in size and fluctua- tion is finally detected; then follows suppuration by an opening either in the integument or the con- junctiva. As a rule, in cellulitis there is a tendency to complete recovery; however, in some cases the in- flammatory action is so great that the ball partakes of the general inflammation, and as a result there is occasionally a loss of vision from atrophy of the optic nerve, suppuration of the cornea, or disorgan- ization of the deeper structures of the eye. Occasionally cellulitis is fatal, death resulting from pyiiemia, meningitis or cerebral abscess. ' The causes of orbital cellulitis are colds, trau- matism, extension of inflammation from contiguous parts (as in erysipelas), tuberculosis and syphilis (generally from syphilitic caries of the bones). Treatment, — First warm fomentations, consist- ing of water alone, as hot as can be borne, and changed often. Never apply poultices of any kind about the eye. Then as early an evacuation of the pus as possible. Tumors of the Orbit. Tumors of the orbit consist of cystic tumors^ vascular tumors and malignant tumors. 1. Ci/stic Tumors. 54 TEXT -BOOK OF OPHTHALMOLOGY. The most frequent of these is the dernioid cyst, a congenital tumor, but which often grows to con- siderable size after birth. The dermoid cyst, although classified as an or- bital tumor, cannot be said strictl}^ to be such, as it is always found in the integument, not within the orbit, but at its ujjper and outer, or upper and inner angle. The dermoid cyst consists of subaceous matter. In removing the cyst care must be taken to dissect out the entire cyst, for even a part of it re- maining behind is liable to give rise to a recurrence of the tumor. 2. Vascular Tumor. The different forms of vascular tumor, rarely, although occasionally, occur in the orbit. They are aneurism and angiomata of the orbit. The aneurism consists of dilated vessels, and the angiomata of new growths consisting principally of blood vessels. The angiomata consists of tw^o forms, the tele- angiectasis and the tumores cavernosi. The teleangiectasis are congenital, and consist of bright red spots in the integument of the lids, from w^hich it gradually extends to the orbit. The tumores cavernosi lie beneath the integu- ment of the lids, which is protruded forward, through which is seen the bluish lustre. Cavernous tumors usually develop in the orbit TUMORS OF THE ORBIT. 55 first, and oroAving, gradually push the eye-ball for- ward. Vascular tumors of the orbit vary in size. Ac- tive bodily exercise, and the acts of crying, coughing, etc., increase their volume, while pressure upon the eye toAvard the orbit diminishes their size. If the size of the tumor increases to such an extent as to endanger the eye, surgical procedure must be instituted. If the tumor is sharply defined and is encapsu- lated, it should be removed. If diffused, electrolysis is indicated. 3. Malignant Tumors of the Orhit. The malignant tumors of the orbit may be classed as the sarcomata and carcinomata. The orbital sarcomata take their origin in the orbit proper, that is from the bone and periosteum, from the cellular tissue, the optic nerve and its sheaths, and from the lachrymal gland. Orbital sarcomata are enclosed in a covering of connective tissue. They are usually rounded and soft in consistence. There is a form of sarcomata that develops pri- marily in the eyeball. They usually have their origin in the choroid or retina, and after bursting through the sclerotic, fill the orbit and push the ball forward. The carcinomata of the orbit do not usually have their origin in that cavity, but in the conjunctiva or the lids, and extend backward. 56 TEXT -BOOK OF OPHTHALMOLOGY. Carcinomata of the orbit proper have their origin in the lachr^^mal gland. All malignant tnmors are of serious import, no matter where the origin of the affection, whether in the orbit proper, in the lids or conjunctiva, or within the eyeball itself. If operative treatment is successful (and no other is), it should be resorted to at a very early date. Exophthalmic Goitre. Exophthalmic goitre (Basedow's Disease; Grave's Disease) is a condition in which there is more or less prominence of the eyes and with which there is enlargement of the, thyroid gland, and paroxysmal palpitation of the heart. Exopthalmic goitre is not a disease per se of the eyes or the orbit, but is due to a condition of the general system in which the brain, heart, and the alimentary tract are more or less implicated. The student is referred to treatises on general medicine for the consideration of this subject THE DISEASES OF THE IvACHRYMAL GLAND. 57 CHAPTER m^ SECTION I. The Diseases op the Lachrymal (Iland. CHE lachrymal gland is subject to the following affections: Inflammation-'^, nypcrtropliy. Can- ceroiis Groicths, and Fistiilae. Inflammation of the lachrymal gland may be acute or chronic. Acute inflammation of the lachrymal gland is indicated by severe darting pain extending from the orbit over the forehead and side of the head. The coniunctiva becomes much congested and chemotic, and the lids are very oedematous. The globe of the eye is pressed downwards and forwards, or inwards and backwards. Like all inflammatory actions, it terminates either in resolution or suppuration. If, in resolu- tion, the gland is gradually reduced in size, and there is general subsidence of the swelling and congestion of the adjacent tissues. If the inflammatory condition ends in suppura- tion, then there will be felt fluctuation at the upper and outer part of the orbit, w^hich after a time will burst and discharge through one or more openings in the upper lid. In the chronic form, the periosteum and the bone in the vicinity of the gland become involved, 58 TEXT -BOOK OF OPHTHALMOLOGY. which usiiall}^ results in a fistula, which remains^ open as long as there remains diseased portion of bone. Treatment in the early stages of the acute form consists in the application of cold compresses to the parts affected. If suppuration is inevitable, then the evacua- tion of the pus at the first evidences of fluctuation. After the contents are thoroughly discharged, the wounds must be antiseptically dressed. The more thoroughly the pus sac is cleaned, the less liable are we to have periostitis and necrosis of the bones of the orbit. It is mostly the neglected cases of sUj^puration of the lachrymal gland that are followed by periostitis and necrosis. Hypertrophy of the lachrymal gland is indicated by the protuberance of the parts in the vicinity of the gland and may be easily felt behind the outer part of the apjDer lid. It is painless, nodular and increases in size very slowly and, like acute inflammation, may gradually disappear or may suppurate and result in a chronic periostitis or necrosis of the bones of the orbit. In the treatment of hypertrophy of the lach- rymal gland, absorption is often effected by the local application of the tincture of iodine. That this treatment may be most effective, the integument over the gland must be kept irritated from its use. At the same time constitutional remedies, as the iodide of iron, fresh air, and good nourishing food THE DISEASES OF THE LACHRYMAL GLAND. 59 must be relied npon in the hope of promoting the absorption of the tumor. In ease of chronic enlargement of the gland, it may be removed. Should the gland suppurate, it should be treated on the same aseptic principles as mentioned in acute suppurative inflammation. The time is past for hastening suppuration by hot poultices and the like. At the first indication of suppuration the parts must be laid open, and the contents evacuated, and the pus sac thoroughly cleansed with antiseptic solutions. Cancerous groicths of the lachrymal gland are occasionally met, and are sarcomatous or carcmo- matoiis. In sarcoma of the lachrymal gland the growth is painless and usually slow. In carcinoma the growth is also slow and pain- less, but other glands of the body become enlarged and evince the malignancy of the affection. The treatment for cancerous growths is removal as soon as the diagnosis is established. The gland can be removed without serious detri- ment to the eye. Fistula of the lachrymal gland is the result of an abscess or an injury. It is easily diagnosed by the clear fluid which constantly drains from it. The treatment is to establish drainage into the conjunctival sac, the best manner of which is to pass a probe along the course of the fistula, then evert the lid while the probe remains, and cut down upon 60 TEXT -BOOK OF OPHTHALMOLOGY. the probe through the conjunctival surface. In this way another fistulous opening will be established and the secretion thus conducted to its proper des- tination. The mouth of the fistulous opening on the skin should be cauterized, and the wound dressed anti- septicallj. SECTION II. Diseases of the Lachrymai. Apparatus. The lachrymal apparatus, consisting of the canaliculi, the sac, and the ducts, is liable to the in- flammations usual to mucous surfaces, the chief effect of which is an impediment to the transmission of the secretions from the eye into the nasal cavity. When such an obstruction exists, the condition is known as epipliora, stillicidium laclirymarum, or watery eye. The causes of obstruction of the lachrymal pas- sages are numerous; the puncta may be displaced as from an ectropion, so that the tears cannot enter, or the canaliculi may be obstructed from an inflam- mation of the mucous membrane of that part of the passage, or the obstruction may occur from like causes in the sac or ducts. The lachrymal sac is occasionally subject to acute inflammation, the result of which is an abcess. DISEASEvS OF THE LACHRYMAL APPARATUS. 61 This condition is known tiHhnically as (hni/io- eystitis. Acute hifiininudflou of the Idchri/iiKi! .sument of the lids, together, often, with hypertrophy of the cellular tissue. Ptosis, from paralysis, should be treated by electricity. Should this fail to establish innerva- tion, surgical inter fertmci^ may become necessary. Excess of integument may be remedied by excision. Treat )iient. — The integument is neatly excised along a line of the fold, usually in a horizontal di- rection, together with any hypertrophied tissue which may exist, after which the edges are neatly united by as many sutures as are necessary to obtain perfect coaptation of the edges of the wound. All operations upon the lids, entailing a loss of integument, must be carefully made, so that the normal contour of the lids may not be interfered with to any great extent. The removal of too much integument, resulting in an ectropion, would be a serious consequence. Ectropion. Ectropion is that condition of the eyelid in which it is everted, or turned out away from the eye ball, and the conjunctival surface exposed. This condition generally affects the lower lids. It is mostly caused by contraction of the integument of the lids, as a result of wounds from burns and other injuries. It frequently follows blepharitis 78 TEXT -BOOK OF OPHTHALMOLOGY. marginalis. Ectropion in aged persons is frequently due to atroph}^ of the orbicularis palpebrarum. It affects mostly the lower lids, but the upper lid may also suffer from the same condition. Ectropion may be partial or complete. Ectropion is partial when only a part of the lid is everted. Ectropion is complete when the entire edge of the lid is everted. Ectropion is also acute or clironic. Ectropion is acute when due to spasmodic con- traction of the orbicularis palpebrarum in ophthal- mia neonatorum, or other conditions, in which there is great tumefaction of the conjunctiva. Chronic ectropion is usually caused by wounds of the integument of the lids. It also follows severe forms of blepharitis marginalis, and paralysis or atrophy of the orbicularis palpebrarum in senility. The most annoying complication in ectropion is the irritation of the conjunctiva from its exposure to the air and dust, and the epiphora caused by the displacement of the puncta. Treatment. — The treatment for ectropion varies with the condition. In the acute form, the inflam- mation must be reduced on general principles. If there is much chemosis, excision or scarification of the protruded conjunctiva gives great relief. Also, compresses of cotton, dipped in yqvj warm water, as warm as can be borne, will prove valuable in re- ducing the inflammation. ECTROPION. 79 The various operations recommended in ectro- pion are applicable only in the chronic variety. However, many of the worst looking cases of this variety will yield to medical treatment, especially the ectropion of the lower lid of old persons, where the conjunctiva is thickened and the tissues relaxed. In cases of this kind the exposed conjunctiva should be touched, once a week, with the solid stick of argenti nitras. The operator should have at hand a saturated solution of sodium chloride, to immediately apply to the parts to which had been applied the argenti nitras. This application is for the purpose of neutral- izing the effect of the nitrate of silver, so that its irritating influence will not be carried farther than intended. A few applications of this kind wall generally correct the most intractable ectropions. There are many operations recommended for ectropion, the most important of which are the Argyle Robertson method, the Adams operation, Wharton Jones operation, and many others, which are modifications of those mentioned. The Argyle Robertson method is adapted, prin- cipally, to those long-standing cases due to thick- ened conjunctiva and relaxed tissue, wherein the tarsal cartilage loses its normal shape. The following is his description as given in the Ophthalmic Review, February, 1884: "The materials required are: 80 TEXT -BOOK OF OPHTHALMOLOGY. "1. A piece of thin sheet-lead about 1 inch long and j inch broad, rounded at its extremities, and with its cut margins smoothed. This piece of lead must be bent with the fingers to a curvature corresponding to that of the eyeball. Figure 16. (After Swanzy.; "2. A waxed silk ligature about 15 inches long^ to either extremity of which a long moderately curved needle is attached. '^3. A piece of fine india-rubber tubing (the thickness of a fine drainage-tube). "The operation is performed by perforating the whole thickness of the lid with one of the needles at a point (b) one line from its ciliary margin, and a quarter of an inch to the outer side of the center of the lid. ECTROPION. 81 "The Deedle having been drawn through (at a), is passed directly downward over the conjunctival surface of the lid, till it meets the fold of conjunctiva reflected from the lid on to the globe, through which the needle is thrust — the point being directed slightly forward — and pushed steadily downward under the skin of the cheek, until a point (d) is reached about 1 inch or 1;^ inch below the edge of the lid, when the needle is caused to emerge, and the ligature is drawn through. The other needle is, in like manner, thrust through the edge of the lid at a corresponding point {¥) a quarter of an inch to the inner side of the middle of the lid, then passed over the conjunctival surface of the lid through the oculo-palpebral fold of conjunctiva, and downward under the skin, till the point emerges at a spot (d^) a quarter of an inch outward from the point of emer- gence of the first needle (d). "The ligature is kept slack, or is slackened so as to permit of the piece of lead being introduced under the loops of the ligature that pass over the conjunctival surface of the lid, and of the piece of india-rubber tubing (c) being slipped under the loop at the edge of the lid (between h and ¥). The free ends of the ligature are now drawn tight, and tied moderately tightl}^ over a lower part of the india- rubber tube. The excess of india-rubber is cut off — about a quarter of an inch beyond the ligature — and the operation is complete.'' 82 TEXT -BOOK OF OPHTHALMOLOGY. Adam-s Operation: u^\ ^^" I Figure 17. (After Meyer.) Adam's method is adapted to such cases of ectropion as are due to cicatricial changes in the integument and tissues of the lid. It consists in excising a triangular piece through the entire thickness of the lid, and bringing the lid into its normal position by fine sutures. Care must be taken not to excise too much, as the result may be contrary to that which was desired. (Adam's Operation). Wharton Jones' Operation: This operation is applicable principally to the lower lid, where the ectropion is caused by a cicatrix of the integument. The cicatrix is included in two convergent in- cisions beginning near the angles of the eye, and uniting on the cheek in the shape of a V. The in- tegument included in the incision is dissected up and made thoroughly movable. After this, the lid KNTROPION. 83 is restored to its norinal position and the lips of the wound finely sutured, when the edges will present a Y shape. (Fig. 18 and 19). Figure 18. (After Meyer.) Figure 19. (After Meyer.) There are other methods, as Deffenbach's, Arlt's, Wolf's, etc., but as they are principally modifications of those already mentioned and more or less diflflcult to perform, the modus operandi of each is omitted. The fact, in regard to all those cases requiring surgical treatment, is, that each method, no matter to what case it is applied, requires some modifica- tion; and the practical surgeon will vary from set rules and adopt such procedure as his mechanical ingenuity dictates. Entropion. Entropion is a condition of the eyelid charac- terized by a turning in, or an inversion of its edges against the ball. Entropion is usually due to some organic 84 TRXT - BOOK OF OPHTHALMOLOGY. change in the structure of the lid, as cicatricial con- tractions of the conjunctiva or tarsal cartilage, or to spasm of the orbicularis palpebrarum. If the entropion is due to cicatricial changes as before indicated, it is usually the result of a trachomatous condition of the lid, and affects prin- cipally the upper lid. When the entropion is due to spasm of the or- bicularis muscle (spastic entropion), it usually af- fects the under lid, although it may affect both. This condition is usual in old people who have had an operation upon the eye, as for cataract, which necessitates the use of a bandage for some time. It also is seen in cases of severe blepharospasm and photophobia, in children principal^,' as a result of corneal ulcer. Treatment. — Where the entropion is caused by organic change in the lids and especially in the tar- sus, an operation is usually necessary to correct the defect. I have, however, in some cases been able to correct the defect by the continued use of collodion. It should be applied, with a camel's hair brush, along the edge of the lid and covering the entire portion of the lid over the tarsal cartilage. As soon as it becomes detached, it can be reapplied. I have kept this treatment up indefinitely in both the spastic and organic forms with much success. In severe cases of the sj)astic form, no matter from what cause, a canthotomy is the most to be relied upon. This is especially the case in the en- ENTROPION. 86 tropion due to the blepharospasm and photophobia as the result of corneal ulcer. In the unyielding cases of the organic form of entropion, there are several methods of operation, owing to the condition of the parts requiring cor- rections, which have been recommended, the most practical of which are Arlt's Method and Streat- field's Operation, which are given below. Arlt's Method as described by Juler: "A small double-edged straight knife is inserted at one or the other end of the eyelid between the cilia and the meibomian ducts, and its point is made to come out through the skin about two millimetres above the lashes.. It is then made to cut its way along the whole edge of the lid, and thus forms a bridge of tissue containing the lashes only. A sec- ond incision is now made from the two extremities of the first, curving upwards to the extent of three or four millimetres. This forms a semilunar flap on the upper lid which must be dissected off. The bridge of skin containing the cilia has now to be shifted upwards, and its upper edge attached by sutures to the skin of the lid, its lower edge being left free. Simple water dressing is all that is neces- sary." StreatfieUrs Operation: "The lid is held with compressing forceps, the flat blade passed under the lid, and the ring fixed upon the skin so as to make it tense and expose the 86 TEXT - BOOK OF OPHTHALMOLOGY. edge of the lid. An incision with the scalpel is made of the desired length, just through the skin^ along the palpebral margin, at the distance of a line or less, so as to expose, but not to divide the roots of the lashes; and then just beyond them the incision is continued down to the cartilage (the ex- tremities of this wound are inclined toward the edge of the lid); a second incision, further from the pal- pebral margin, is made at once down to the car- tilage in a similar direction to the first, and at the distance of a line or more, and joining it at both extremities; these two incisions are then continued deeply into the cartilage in an oblique direction toward each other. With a pair of forceps the strip to be excised is seized, and detached with the scalpel." The remainder of the operation is described by Juler as follows: "Three sutures are then introduced as follows: A small curved needle, armed with fine silk, is passed first through the lower edge of the skin wound, then through the upper edge of the groove in the tarsus, and the two ends tied tightly together. The upper edge of the skin wound is thus left free, and unites very well without sutures." Trichiasis. Trichiasis is that condition in which the eye- lashes turn in upon the ball, and irritate the eye. As this condition is usually the result of an DISTICHIASIS - ANKYLOBLEPHARON. 87 ectropion, the treatment given under that head is sufficient. DISTICHIASIS. Distichiasis is that condition which indicates a superfluous or distorted growth of the eyelashes, in addition to the normal row, so arranged that they turn in upon the eye and irritate it. Most all operations for this condition, outside that given for ectropion, have not proven eminently satisfactory, and have been generally rejected by the modern oculist, for the principal reason that the normal contour of the lids has been more or less interfered with. In view of this fact, electrolysis is no doubt the very best method to be applied in these cases. ANIvYLOBLEPIIAKON. Ankylohlepharon signifies an adhesion between the edges of the lids, and may be partial or complete. In partial ankyloblepharon only a part of the edges of the lids are adhered. In complete ankyloblepharon the entire edges of the lids are adhered. Ankyloblepharon may be congenital, traumatic or the result of a disease of the lids. Treatment. — The treatment, no matter what the cause, consists in dividing the adhesion with the knife or scissors. If a knife is used, the eye should be protected with a grooved director behind the 88 TEXT -BOOK OF OPHTHALMOLOGY. parts to be divided, in order to fully protect the eye. A pair of scissors with a blunt point is the best instrument for this purpose. It is a small matter to divide the adhesions in ankyloblepharon, but to keep them separated is quite another matter, for the tendency is to reunite. For this purpose the palpebral conjunctiva of one of the lids, preferably the lower one, should be stitched to the skin of the lid. It is often neces- sary to dissect the conjunctiva off the edge of the lid, and draw it out in order to meet the skin to which it is to be stitched. We must be careful that this procedure is well carried out at the angles of the lids. It frequently occurs, generally as a result of burns, that the ankyloblepharon is complicated with a symblepharon, in w^hich case we should endeavor to ascertain the extent of the latter prior to under- taking an operation, for if there are general adhe- sions between the lids and the globe, the operation will prove a failure. The extent of the adhesion can be fairly well ascertained by watching the movements of the eye behind the lids, or better by passing a probe into an opening and ascertaining how far it can be in- 'troduced in all directions. Symblepharon. SymUepharon is an adhesion between the con- junctiva of the lids and the globe, and is complete or partial. SYMBLEPHARON. 89 In complete symblepharon the palpebral con- junctiva is more or less united to that of the globe, and the cul-de-sac participates, to a greater or less extent, in the condition. When the symblepharon is partial, the palpebral conjunctiva is united to the ball by larger or smaller bands, but leaving the cul-de-sac free. Symblepharon, whether complete or partial, is usually the result of burns, and is more or less se- rious owing to the extent of the surface transformed into cicatricial tissue. Treatment. — The treatment of symblepharon depends to a great degree upon the extent of the adhesions. If the adhesions are complete, involv- ing the entire cul-de-sac, no operation should be un- dertaken. When the adhesions are partial, the treatment depends upon their situation and extent. If there is but one or two- small adhesive bands, we can often succeed in separating them by means of a ligature tied very tightly round the cicatricial tissue. If, however, the band is large, it can be divided into two, or even more parts, by ligatures surrounding each part, as in the small band. In case of complete symblepharon, where only a part of the cul-de-sac is involved, the following operation recommended by Meyer is one of the best methods. It is, in his own words, as follows: "The base of the symblepharon is pierced with a triangular needle, parallel with the palpebral fold, 90 TEXT -BOOK OF OPHTHALMOLOGY. and inserted as deeply as possible. Then a leaden string is inserted in the wound made by the needle, and its two end^ are moulded so as to fit the angles from which they emerge. Some surgeons unite the ends of the thread, and, from time to time, tighten the knot. The thread is left in situ till the wound is cicatrized, when the adhesion is cut in the same way as for incomplete symblepharon." Figure 20. (After Meyer.) Blepharophimosis. BlepharopJiimosis is that condition of the pal- pebral fissure in which it is contracted, and thereby diminished in length. In this condition the angles of the lids are brought closer together than normal and is usually the result of a trachoma. Treatment. — Blepharophimosis is remedied only by an operation known as canthoplasty. One of the most simple and satisfactory operations for BLEPHAROPHIMOSIS. 91 canthoplasty is that of Meyer, and is described as follows: "The external commissure is divided in its entire thickness in a line with the direction of the palpebral fissure. This section may be made with a bistoury, the point being gently inserted between the eyeball and the external commissure. "The entire thickness of the integuments is then transfixed with the point of the knife from w^ithin outwards, and the whole commissure is easily di- vided by pushing the bistoury outwards." Figure 21. (After Meyer.) "The operation is still more easily performed with straight scissors, one blade being introduced behind the commissure; the wound in the skin should always be a few millimetres longer than that in the conjunctiva. 92 TEXT -BOOK OF OPHTHALMOLOGY. The section of the commissure being thus com- pleted, an assistant draws the margins of the wounds upwards and downwards, so as to change a horizon- tal into a vertical section. The surgeon takes hold of the conjunctiva near the centre of the section, and passes through it a very fine needle furnished with a silken thread; he then lets go the conjunctiva, and takes hold of the external skin also at the centre of the section; the needle is carried through the skin, and on tying the suture the corresponding margins of the skin and mucous membrane are brought together. In like manner two sutures are also inserted near the angles of the wounds.'' Epicanthus. Epicanthus is a congenital malformation of the lids, in which a fold of the integument at the inner canthus covers the caruncle to a greater or less extent. This condition is caused by superfluous integument over the bridge of the nose betAveen the eyes. * Epicanthus can be improved by removing an oval piece of the redundant integument from the bridge of the nose, the amount removed being regu- lated by the extent of the deformit^^ The margins of the wound must be so shaped as to insure perfect coaptation, and the edges must be held together by hair pin sutures. DISEASES OE THE CONJUNCTIVA. 93 CHAPTER V, SECTION I. Diseases of the Conjunctiva. CHE conjunctiva is subject to various affections, which may be designated as inflammatory and non-Inflammatory. By far the largest percent are inflammatory. The following may be considered under the head of inflammatory diseases of the conjunctiva: 1st. Hyperaemia of the conjunctiva, 2nd. Inflammation of the conjunctiva. (Serous, Mucupurulent, Purulent, Plastic, and the Asso- ciated). 1st. Hypersemia of the conjunctiva is that con- dition which is simply marked by an excess of blood in that structure. Hyperaemia is active or passive. Active hyperaemia is due to an increased inflow of blood. Passive hyperaemia is due to an obstructed out- flow of blood. Hyperaemia of the conjunctiva is also acute or chrcniic. The causes of hyperaemia of the conjunctiva are numerous, among which are: uncorrected ametro- pia, beginning presbyopia, incipient cataract, slight 94 TEXT -BOOK OF OPHTHALMOLOGY. opacities of the cornea, local irritants, as foreign bodies, such as dust, wood or tobacco smoke, cold winds, the abuse of alcohol, and associated diseases, as nasal catarrh, lachrymal obstruction and blepha- ritis marginalis. The point of transition between hypersemia and inflammation is so subtile that it is impossible to determine just w^here hypera^mia ends, and where inflammation begins. The symptoms of hypersemia of the conjunctiva are slight congestion of the vessels, swelling of the conjunctival follicles, photophobia, lachrymation, and a hot stinging sensation. Treatment. — Remove foreign body; correct re- fractive error (many cases of hypersemia are caused by wearing glasses that are not properly centered, or otherwise not projDerly adapted to the eye) ; open obstructed tear duct; apply proper remedies to associated diseases. Locally, R. — acid boracic, grs. v, aqua destil, oz. i. Mix and filter. To be instilled into the eye three or four times a day in acute hypersemia. If the hypersemia is chronic and caused from some of the associated diseases, as nasal catarrh, blepharitis marginalis, use the following: R. — hydrastin, gr, ss acid carbolic (pure) gtt, i morphia sulph, DISEASES OF THE CONJUNCTIVA. 95 glycerine drs ii. aqua destil, drs vi. First add the carbolic acid to tlie glycerine, and the other ingredients to the aqua destil; then unite the two solutions and filter. A few drops in the eye three or four times a day. The advantage of this application is that the anaesthetic effects are ver}^ lasting, which is prin- cipally due to the carbolic acid. Always be sure that the carbolic acid is pure. Besides the anaesthetic effects of carbolic acid, its antiseptic properties are not to be ignored in many affections of the eye. If the hypera^mia is active, cold applications are indicated. If passive, hot fomentations, but never poultices in any affection of the eye^ Raw beef, rotten apple, scraped potato, and all similar so called remedies, are only mentioned to be emphatically condemned. 2nd. Conjunctivitis. Conjunctivitis is an inflammation of the con- junctiva per se. When the deeper structures become involved, the term ophthalmia should be applied. The following division for the study of the dif- ferent forms of conjunctivitis (the ophthalmias) is presented. This division being founded upon the character of the secretions, is considered the most logical arrangement. 96 TEXT -BOOK OF OPHTHALMOLOGY. Conjunctivitis, (Ophthalmia] Serous Muce - purulent Purulent Plastic Acute catarrhal Chronic catarrhal Trachoma {Neoi Bleu Neonatorum orrhceal Croupous Diphtheritic Serous Conjunctivitis. Serous conjunctivitis is characterized by simply a watery discharge froni the eyes. There is in- flammation of the palpebral, fornix and ocular con- junctiva^, characterized by congestion and redness of these parts. There is usually a sensation as if sand or other foreign body were in the eye. There may or may not be photophobia. As long as the discharge is serous (water^O, it is classed as acute catarrhal, and the discharge is not considered con- tagious. As soon, however, as mucus or muco-pur- ulent matter is found in the discharge, it ceases to be acute catarrhal, but merges into the muco-purulent variety, and the discharge from the eye is regarded as contagious. The causes of serous conjunctivitis are usually due to climatic changes (colds), foreign bodies in the eye, irritating. substances in the atmosphere, as dust^ smoke, etc. Eye strain is also a frequent cause. SEROUS CONJUNCTIVITIS. 97 Trvaiiuvuf. — Examine the eye carefully to as- certain the presence of foreign body. A hair from the lid, a cinder or other forei*»n body is very liable to fall upon the ball, when, if it does not adhere (most always to the corneal surface), it is either sw^ept away by the hichrymal secretions, or is car- ried by the action of the lids to the under surface of either lid, mostly, however, to the under surface of the upper lid. In all cases of conjunctivitis, whether there is a history of contagion or not, examine the eye thor- oughly for foreign body: First: Cocainize the eye by instilling a few drops of a 4 per cent solution on its surface, or between the low er lid and the ball. Then inspect the cornea carefull}^, viewing it from several direc- tions. It frequently occurs that a foreign body em- bedded on the surface of the cornea is not seen be- cause w^e do not observe the point from the proper direction. Then evert the upper lid; generally if there is a foreign body in the eye, it will be found adhering to the palpebral surface of the upper lid. As this procedure will not give you a full view of the entire conjunctival surface, insert sohie smooth instrument under the everted lid, and at the same time direct the patient to look down. Raising the lid with the instrument, you are enabled to inspect the entire surface of the superior fornix. This is imi^ortant, for it occasionally occurs that a foreign body drifts into the superior fornix. I 98 TEXT -BOOK OF OPHTHALMOLOGY. once removed' a stem of ragweed, to which was at- tached two or three of the seed, that had remained in this part of the eye for more than six months. The surface of the inferior fornix can be brought to view by making slight pressure with the finger upon the integument of the low^er lid and pressing it toward the cheek bone, at the same time directing the patient to look upward. If no foreign body is found and there is no his- tory of irritation from dust, smoke, or extraneous causes, then we can attribute the condition to cli- matic changes, or to eye strain due to refractive irregularities, or to overwork. To abort the inflammatory condition, the follow- ing solution should be applied to the conjunctival sac once a day: R. — argenti nitras (cryst.) gr 1 aqua destil. oz i Mix. Invert the upper lid and apply to its conjunc- tival surface with a small cotton applicator, well saturated with the solution. x\t the same time if the lower lid is slightly pulled away from the ball, the inferior fornix will receive a portion of the solu- tion — if immediately after the upper lid is returned to its place, it is gently lifted from the ball by the cilia, the solution will come in contact with all parts of the conjunctival sac. Together with the above, instil a few drops of F. No. 2 into the affected eye three or four times a MUCO-rURULRNT CONJUNCTIVlTlvS. 99 day or of toner if nocossary. 1 instruct my patients to apply the solution whcMiever the eye becomes painful. If tlie lids become matted toj^ether in the morn- ing, apply to their edges upon retiring at bed-time a very small portion of vaseline, just enough to mois- ten the roots of the cilia. Frequent attacks of serous conjunctivitis is in- dicative of eye strain and the eyes should be thor- oughly examined in that direction as soon as the in- flammation subsides. There are many other acceptable remedies for serous conjunctivitis besides those which have already been mentioned, but avoid the sulphate of zinc, sugar of lead, sulphate of copper and other strona: caustics, as their use in any case is of doubt- ful benefit, but is often fraught with positive injury. MUCO-PlJRULENT CONJUCTIVITIS. Muco-purulent conjunctivitis is characterized by more or less chronic inflammatory condition of the conjunctiva. There is loss of lustre of the pal- pebral conjunctiva together with congestion of both the palpebral and ocular conjunctivae. There is usually present photophobia and often, although not always, blepharospasm. There is a serous and mucopurulent discharge, and the lids are glued together on awakening in the morning. There is a sensation as of sand or other gritty substance in 100 TEXT -BOOK OF OPHTHALMOLOGY. the eye, caused by the presence of mucus and the enlarged papillae. In severe cases the lids become thickened, there is blepharitis, there is increased conjunctival irrita- tion caused by closure of the punctum, or its ever- sion from the ball, and the resulting epiphora. In severe and protracted cases of mu co-purulent conjunctivitis, there are liable to be corneal compli- cations, such as pannus and corneal ulcer. In case of either, the photophobia and blepharospasm are usually severe. As a neglected hyperjemia or a serous conjunc- tivitis may develop into the muco-purulent form, the causes are practically the same with the exception that a muco-purulent conjunctivitis is liable to be produced by a contagion. Here is a matter of great importance: micro- organisms are present in ever^^ case of muco-purulent conjunctivitis, no matter what its cause, or whether it is severe or not, and are liable if they come into contact with an eye to set up not only a muco-puru- lent ophthalmia, but a purulent form of the most severe type. The various terms, "granular lids," "granular ophthalmia," "papillary granulations," "follicular granulations," "trachoma," etc., are in fact synony- mous and doubtless only different forms of muco- purulent ophthalmia. Granulations are not to be regarded as patho- logical formations, but simply changes in the lymph MUCO-PURULKNT CONJUNCTIVITIS. 101 follicles, and the terms "papillary trachoma" and "follicular trachoma" are but different conditions of the lymph follicles, owing perhaps to the different grades of inliammation of the conjunctiva. It has been well demonstrated that "granulations" of the lids differ from the pathological granulation-tissue in that the mucous membrane in granulated lids is not ulcerated. Juler claims that the granulations are eleva- tions composed of aggregations of lymphoid cells, beneath the mucous membrane, with a partial fatty degeneration of these cells nearest the surface. Although muco-purulent ophthalmia, from its contagium or otherwise, may attack anyone, yet cer- tain individuals are predisposed to it, especially those living in poorly ventilated rooms, and those w^hose nutrition is enfeebled by syphilis or tubercu- losis. Muco-purulent ophthalmia is extremely contag- ious, and on account of the diverse ways in which its contagium is spread, it is almost sure to attack every inmate, when it becomes developed in crowded institutions, such as those for destitute children. These children, as a rule, are not of vigorous consti- tution ; many of them being of scrofulous or tubercu- lous habit are very liable to become affected with contagious diseases in general. Mucopurulent ophthalmia is so unrestricted in its extent both as it regards the field it invades and the character of the attendant inflammation that 102 TEXT -BOOK OF OPHTHALMOLOGY. scarcel}' two cases are similar except in a few gen- eral features, therefore the impossibility as well as impracticability of anytliing like a specific medica- tion. The palpebral surface of the conjunctiva may alone become affected, as it usually is the point of attack in the incipienc}^ of the affection; or the en- tire conjunctival sac may become involved. Not only may the conjunctiva suffer, but the deeper structures often become seriously implicated. A clear distinction should be made between muco-purulent conjunctivitis and muco-ijurulent ophthalmia. When the affection is confined to the conjunctiva alone, without the involvement of other adjacent structures, then the affection is a conjunc- tivitis, but when other structures become involved, as the lymph glands and follicles, and the various secretory and excretoiw ducts, then the affection should be known as an ophthalmia. Treatment. — The first requisite and indispensa- ble in the treatment of muco-purulent ophthalmia is a most thorough and pains-taking cleanliness. This is essential, not only for the good of the patient, but in order that the affection may not be communicated to others. As there is a condition of sepsis, antiseptics are always indicated in advance of, as well as in connec- tion with other treatment. The kind of antiseptic is also a matter of inport- ance, in eye affections especially. MUCO-PITRULKNT CONJUNCTIVITIS. 103 Bi-cliloride of mercury, both a« a germicide and as an antiseptic, heads the list, and the solution of 1-5000 is indicated in muco-purulent ophthalmia of the chronic non-inflammatory variety. I have known cases of this kind improve rapidly under its use, and many such cases I believe require no other treatment. But where there is much inflammatory action, as in complications, as of pannus or corneal ulcer, then the bichloride of mercury is contra-indicated. Its use in such cases very frequently increases the in- flammation to a very exasperating degree. Carbolic acid as an antiseptic fills an important place in the treatment of diseases of the eye, not for its antiseptic qualities alone, but for its anesthetic effects. Where there is much inflammation, the car- bolic acid solution (2 to 4 per cent) is indicated. The soothing influence which the solution has in these cases, especially where complicated with corneal ulcer, is remarkable. Its effects in many of these cases is as prompt as cocaine and much more lasting. When it is determined which antiseptic is to be used, all of the secretions should be removed with pledgets of absorbent cotton, after which the lids should be thoroughly washed with sterilized water. The antiseptic should be so applied that it will come in contact with all parts of the conjuncti- val sac. This can be done by first applying it from a dropper to the conjunctival surface of the everted 104 TEXT -BOOK OF OPHTHALMOLOGY. tipper lid; next, the lower lid should be pulled slightly away from the ball, and the solution from the dropper, as before, is instilled into the lower for- nix, filling it. Then by slightly everting the lower lid, and at the same time tilting the everted upper lid away from the ball, b}' a slight pressure upon its edge, the lower lid thus everted can be dextrously pushed up under the upper lid, and will carry with it the solution to all parts of the conjunctiva. Purulent Ophthal-mia. Purulent ophthalmia is an acute inflammatory condition of the conjunctiva, characterized by a high state of inflammation and a profuse purulent or muco-purulent discharge from the eyes, caused b}^ inoculation from a specific contagium. This condition is also known as acute blen- norrhoea, which signifies a i3rofuse discharge of mucus, but purulent ophthalmia is considered a better term, as the discharge consequent to the af- fection partakes of that character. Purulent ophthalmia is considered under two heads, viz. gonnorrhoeal ophthalmia and ophthalmia neonatorum, Gonorrhoeal ophthalmia is caused from infec- tion with the gonococci, the specific contagium, or morbid principle of which incites the disease. The means of conveyance of the poison into the conjunctival sac in gonorrhoeal ophthalmia are too numerous to mention; the most common, however. PURULENT OPHTHALMIA. 105 beinff from uncleanliness, in not keepin*;- the hands well cleansed after nianipnlation of the affected parts. The conta^um can also be carried to the eye by washing- in the same basin and wipinj> upon the nap- kin or towel used by one who has the affection. This is a most prolific manner of spreading the disease. The contagium can also be carried with the secretions from the eye to the floor or the street, and after drying may be convey ed to the eye with the dust raised in the sweeping of the floor, or by the wind on the street. In ophthalmia neonatorum there are not so many wa^-s in which the eyes become affected, as it occurs during or after the child's head passes through the vagina, or from inoculation after birth, through negligence of the nurse or mother by con- veying the virus from her fingers, or through the towels while bathing the child. It is a question whether all cases of ophthalmia neonatorum are not caused from a vaginal discharge that is gonorrhoeal; and while such is probably the case in the severer forms, yet it is not sympathetic nor charitable to attribute this cause to all cases. I have seen very severe cases of ophthalmia neonatorum in which the gonococcus could not be discovered in the conjunctival discharge, and which affection was due to a vaginal discharge which was not of the specific gonorrhoeal character. We must also remember in giving our opinions 106 TEXT -BOOK OF OPHTHALMOLOGY. as to the cause, that the discharge may be of gonor- rhoea! origin, and the mother be entirely innocent and blameless in the contraction of the affection. It is therefore the province of the physician to relieve his patient and prevent if possible impending blind- ness, rather than speculate as to the origin of the affection. Purulent ophthalmia, whether in the infant or adult, is a highly inflammable and contagious affec- tion, caused by infection, making its appearance in from two to foui' days after the virus has been brought into contact with the conjunctiva. The symptoms of both forms of purulent oph- thalmia are so similar that it is not necessary to treat of them separately. The first symptom of a purulent ophthalmia is a serous discharge from the eye, soon followed by a serous infiltration of the palpebral and ocular con- junctiva. The infiltration of the ocular conjunctiva be- comes so great that the conjunctiva is forced out- ward between the lids to such an extent that it is impossible, often, to evert them, and in some cases the swelling is so great that the lids are inverted, and the cilia are turned in upon the conjunctiva. This condition of the conjunctiva is known as ehe- This stage lasts from two to four days, during which time the serous discharge changes to the muco- purulent, then to the purulent, in its most virulent and contagious form. PURULENT OPHTHALMIA. 107 The eliemosis now <>radually decreases, but the lids continue to swell, the upper one becoming so large and pendulous that it hangs over the under lid, whose cilia add to the irritation by rubbing against the conjunctiva of the ball and the upper lid. The chemosis and the swelling of the lids, to- gether with the existing conjunctivitis now, by de- grees, slowly subside, the discharge becomes less, and in the course of about four weeks the eye is usuallv left in its normal condition. The affection usually attacks one eye, but in a short time the other becomes affected from a trans- mission of the contagium from its fellow. This is a typical course of an uncomplicated case of puru- lent ophthalmia. But the eye frequently suffers from complica- tions w^hich imperil its safety to a serious extent, the most important of which is the dense chemosis of the ocular conjunctiva. This condition endangers the safety of the eye, because the nutrition of the cornea is obstructed by it. Then follow^ corneal ulcer, sloughing of the whole cornea, and its con- comitant, staphyloma, with entire loss of vision. Although corneal complications are the most to be dreaded, there are others, from the extension of the inflammatory condition, the most important of which is iritis, and often cyclitis and choroiditis. Treatment. — The treatment of the purulent oph- thalmias consists, from the onset, in thorough asep- sis, in all that the term implies. 108 TEXT -BOOK OF OPHTHALMOLOGY. This is a most important matter, for it not only concerns the patient, but all others in the household. I have known all the members of a large family, where no particular concern was given to cleanli- ness, to contract the affection, coming from a single individual. This precaution is necessary whatever the type. In case of the infant, especially, if we have rea- son to suspect an existing gonorrhoea, or even an abnormal vaginal discharge in the mother, the eyes should be thoroughly disinfected immediately after birth, with a 1-5000 bichloride of mercury solution. This I consider much better than Crede's method of applying; a 10 gr. solution of the argenti nitras to the conjunctiva, as a prophylactic; in fact the 10 gr. solution of argenti nitras is too strong for the eyes of an infant, from the fact that the epithelium covering^ the cornea is very delicate, — so very delicate, indeed, that the above solution, if allowed to come into con- tact directly with it, would abrade it to a consider- able extent. In order to thoroughly disinfect the whole of the conjunctival sac, we should use a small bulb syringe with a flattened nozzle which can be easily intruded between the lid and the ball. With this instrument we can thoroughl}^ flush and cleanse the conjunctival sac by gently raising the lid and intruding the nozzle between the lid and the ball, and pushing it as far up into the fornix as possible before expelling its contents, at the same time being careful not to exert any pressure on the PURULENT OPHTHALMIA. 109 ball with the point of the iustnuneiit, but instead, toward the lid. This is very important, especially in case of corneal ulcer, for the least pressure in such case is often very injurious to the eye. More trouble is experienced in tlushinu, the upper cul-de-sac than the lower. As a prophylactic, one flushing, immediately after birth, is quite sufficient; but if the affection has already set in, then the flushings should be kept up at least twice a day. As fast as the purulent discharge accumulates it should be removed with pledgets of absorbent cotton, and a 10 gr. solution of boracic acid should be instilled, by means of a dropper, between the lids, as often as every two hours. If there is much chemosis and swelling of the lids, the application of the solution is not of much importance, from the fact that it comes into contact with but a very small portion of the conjunctival sac. The greatest danger to the eye, as heretofore indicated, is the chemosis, especially when it is so great as to interfere with the nutrition of the cornea. If the chemosis is very dense and is protruded between the lids, and is reflected over the cornea to a greater or less extent, and the lids are swollen so much that they have become inverted, and their edgfes are burrowed deeply into the infiltrated con- junctiva, the best thing to be done is a free canthot- omy, after which warm water fomentations, as hot as can be borne, should be applied to the eyes. The fomentations should be changed as often as 110 TEXT -BOOK OF OPHTHALMOLOGY. every five minutes, and replac^ed with hot ones, which process should be kept up as long as an hour at a time, twice or three times a da^^ Although nitrate of silver has been highly rec- ommended in the purulent ophthalmias, I consider its use as highlj^ dangerous, especially with infants. The structure of the eye of a child a few days old is very delicate, the sclerotic, which is considered the most substantial part, being so thin that the choroid can be seen through it. The cornea, as w^e all know, is as thin and deli- cate in in its structure as the sclerotic, but as its clearness is an indispensable to good vision, it is less able to withstand strong solutions, especially when of doubtful utility. Many authors have recommended as much as a 20 gr. and some even a 30 gr. solution of the nitrate of silver in the purulent ophthalmia of infants. Now while the eye of the adult may be able to withstand these strong solutions, I am very sure that they are positively injurious in children, for if the use of a 10 gr. solution is kept up for even a very few days, the cornea will frequently soften and we will be sur- prised at one of our visits to find that it has given way, and that the iris is protruded through it. Such an occurrence is usually attributed to the disease, when in fact it is the result of the nitrate of silver upon the cornea. It should be remembered that atropine has no mydriatic effect upon the eye of an infant, and for this PLASTIC OPHTHALMIA. HI reason it is uiinecessarv to use it, even if there is ail indication for tlu^ pupil to be dilated. My OAvn experience is that the flushings of the conjunctival sac with the bichloride of mercury solu- tion, 1-5000, is the most satisfactorj^ of all known medications in the purulent ophthalmias of the adult and infant. Plastic Ophthalmia. The plastic forms of ophthalmia are found in the diptheritic or membranous, and the croupous or psuedo-membranous. Plastic ophthalmia is, fortunately, not a frequent affection in this country; however, occasionally we have to deal with a case; but Germany and many of the older countries have suffered very much from its effects. Although plastic ophthalmia is said to be directly traceable to diphtheria, yet cases have been known to exist where no trace of diphtheria could be found, except that upon the conjunctiva. The membrane in plastic ophthalmia is an ex- udation, caused by the coagulation of fibrin. In the diphtheritic form the coagulation of fibrin takes place in the whole thickness of the conjunc- tiva, down to the sub-mucous tissues. This is the most dangerous form of plastic ophthalmia, and sel- dom leaves a patient without more or less permanent loss of vision. 112 TEXT -BOOK OF OPHTHALMOLOGY. In the croupous form the exudation is poured out upon the surface of the conjunctiva, forming a pseudo-membrane, which can be lifted oH* of the con- junctiva, very readily,, with forceps, without injury to it. This form of plastic ophthalmia is of no great consequence, as it never amounts to more than a catarrhal conjunctivitis. The prominent symptoms of diphtheritic oph- thalmia are extreme tension and swelling of the eye- lids, accompanied by a sense of heat, and often, al- though not always, severe pain. The lids are so stiffened by the exudate that it is almost impossible to evert them. This condition of the lids is one of the leading features in the diagnosis of this affection. Diphtheritic ophthalmia is a serious affection^ often destroying the eye within a day after its incep- tion. In some severe forms, treatment is seemingly incapable of the least benefit. The greatest danger in diphtheritic ophthalmia is that the exudate becomes so impacted into the conjunctival and sub-conjunctival tissues that the nutrition is interfered with to such an extent as to cause ulceration and necrosis of the cornea. All cases of diphtheritic ophthalmia, in the course of from thirty-six to forty-eight hours, gradu- ally pass from the plastic stage to that of a purulent character. This is characteristic of the affection, and is accompanied by a return of the flexibility of the lid, in that it is now more easily everted, and by the purulent character of the discharge. PTERYGIUM. 113 Treatment. — TIh^ treatment in the onset, and dur- ing the plastic stage, consists simply of iced cloths to the lids, and the flushing of the eye with the bi- chloride of mercury solution, 1-5000. As soon as the purulent stage sets in, the iced cloths must be changed for hot water fomentations, the same as in the purulent ophthalmias. As a prophylactic, in case the cornea should become involved, the pupil must be kept widely dilated with a 1 per cent solution of atropine, which should be instilled into the eye three or four times a day. It will be very fortunate if the cornea does not become involved before the suppuration begins, as it rarely occurs afterwards, but the tendency is usu- ally to a speedy recovery, with the treatment already laid down for the purulent ophthalmias. Pterygium. Pterygium is a triangular fold of mucous mem- brane, growing out from the conjunctiva of the eye- ball, over the cornea. That part of the pterygium at the apex of the triangle, and attached to the cornea, is named the head: its base, or that part at the canthus of the eye, is termed the body ; and that portion immedi- ately behind the apex, at the sclero-corneal border, is denominated the neck. There are many opinions with regard to the origin of pterygium, but the consensus of all is that 114 TEXT -BOOK OF OPHTHALMOLOGY. the starting point is usuallj^ a Pinguecula, or else an ulcer situated near the sclero-eorneal border, on the conjunctiva. Figure 22. (After Meyer.) Pterygium consists of hypertrophied tissue, of- ten very trifling in amount, but sometimes very con- siderable and unsightly. This morbid growth is fibrous in structure and is not firmly adherent to the cornea and sclerotic. It is covered with conjunc- tival tissue, which surrounds the hypertrophied mass, which is entirely disconnected from the con- junctiva, except at the linear adhesion on its under surface, where it acts in the manner of a pedicle. It seldom reaches or passes the center of the cor- nea, for the reason, perhaps, that the blood vessels which feed it do not extend further, usually, than that point. Although the affection is of little importance, unless it implicates the cornea to such an extent as to obstruct the vision, yet its appearance to many, and especially to its possessor, is more or less repug- PTI^RVGIUM. 115 nant, and patients are <;enerally solicitous to rid themselves of its pre sence. Without atteniptin^i; to discuss the cause of this morbid growth, it is our object to consider the most feasible means for its thorough and permanent re- moval. Authors mention various methods for this pur- pose, which resolve themselves into three plans of operatin,j:>-, viz.: excision, transplantation and liga- tion, or a combination of two or all of these methods; thus, one recommends its entire removal by excision, by dissecting it from its apex to the semilunar fold, where it is excised; another recommends dissection of the apex from the cornea to its base, and then inserting the dissected portion underneath the con- junctiva, where it is held by sutures; another advo- cates the ligation of the base and the dissection and excision of the apex; and finally, another the liga- tion of both the base and apex together with the narrow strip underneath the growth, where the liga- tures are allowed to remain until the growth sloughs away. If any of these methods or any of their combi- nations have given general satisfaction, I am not aware of it; but, on the contrary, oculists usually discourage patients from having anything done with the affection unless it encroaches so far over the cor- nea as to interfere materially with vision. In a practice of more than thirty years, during which time I have attempted the removal of quite 116 TEXT -BOOK OF OPHTHALMOLOGY. a number of these growths by one or another of the methods herein enumerated, I cannot recall more than a half dozen cases in which the result was all that could be desired ; but, on the other hand, many of them were not benefited in the least, the operation frequently having resulted in unsightly cicatrices. Arlt has demonstrated that pterygium enters into the substance oi the cornea, beneath its epi- thelial layer, yet, as previously mentioned, the con- nection is not firm, and its fibres can be readily separted from the cornea with very little effort. A few years ago, before the anaesthetic proper- ties of cocaine were discovered, I attempted to re- move a large pterygium in the case of a man who w^as somewhat under the influence of liquor. I caught the growth near its apex with the forceps. When I was about to separate it from the cornea w^ith the scissors, he made a desperate effort at re- sistance, and caught my arm with which I was holding the forceps so suddenly that I did not have time to relax my hold. It bled freely, and I was fearful that the eye was badly injured. After a con- siderable time I was allowed to cleanse the eye, when 1 found that the pterygium was entirely separated from the cornea and as far back as midway between the sclero corneal junction and the caruncula lach- rymalis. That part of the cornea to which the growth had been attached was somewhat haz}, and presented the appearance of numerous small depressions not PTERYGIUN. 117 larger than i)iii-i)()iiits, showing the points whore the fibres had penetrated the cornea. The patient would not permit me to proceed farther — not even to excise the loose tissue remaining. I recommended the application of cold water to the e^^e and advised him to return dail}^, that I might watch the eye. He went home and, as he suffered no pain, concluded he was doing well enough, and did not return for three weeks, at which time the detached tissue had contracted and I could scarcely see any corneal opacity or other evidence that the eye had ever been affected with pterygium. What I so much feared in this case was that the corneal layers had been separated and, as a re- sult, corneal ulceration; or, on the other hand, infil- tration between the separated layers and a conse- quent extensive opacity. Subsequently I thought little of the occurrence more than to congratulate myself how fortunate I had been in not having destroyed the man's eye, until some time afterwards I was relating the cir- cumstances to a physician, when he gave me the fol- lowing: An old gentleman of his acquaintance had a large pterygium on each eye. He had been having his eyes "treated'' from time to time by different parties, principally traveling "specialists," without benefit, when, in conversation with his family phy- sician, he was informed that treatment in such cases was not generally successful, that his eyes would 118 TEXT -BOOK OF OPHTHALMOLOGY. probably not become worse, and he was advised to desist. The old gentleman had his own idea about the matter, and insisted that the growth would con- tinue to ^'cover the sight'' and in a short time leave him hopelessly blind. He argued that his disease was similar to that of the horse, known as "hooks,'' and that '-hooks" are cured simply by "pulling them off." He concluded to act in his own behalf and, having procured a small pair of forceps, such as is commonly knowm as "eye tweezers," he actually removed the pterygia from both eyes, and without subsequent treatment the procedure effected a per- manent cure. I have ascertained that the affection known as ''hooks'^ in the horse is simph^ an attachment of the membrana nictitans to the cornea, the adhesion be-^ ing, probably, the result of an inliammatory action of this membrane and the ocular conjunctiva. Shortly after this, I presume about two years ago, I noticed in some medical journal that a for- eign oculist, Arlt, I believe, was removing ptery- gium by evulsion, and being greatly interested, by reason of the circumstances just mentioned, I have been anxiously w^aiting to hear with what success. So far I have been disappointed. For the past ten years I have rarely used other means in the removal of pterygium than evulsion. I have not had a great number of cases, but the re- sults have been generally satisfactory. PTERYGIUM. 119 In my first opcM-ations I removed the apex, and as far back as t\w carniiciila laclirymalis, with the forceps, and excised tlie loose tissne with the scis- sors. Afterwards I lij^ated the base first and then removed the j^rowtli with the forceps as far as the lii^ature, and excised as near it as possible. In this I found a great advantage, inasmuch as the ligature prevented haemorrhage and I could operate to a bet- ter advantage. Recently I have discarded the forceps, axid taken in its stead a blunt hook — such as is used in the ope- ration for strabismus — which I find a much better instrument for this purpose. After the base has been ligated the pterygium is separated from its attachment with the blunt hook, by running it under a small portion at a time, especially if the pterygium is large; first separating the thin connection between the ligature and the cornea; then a small i3ortion of the corneal attach- ment at a time, until the whole is removed. The loose tissue is excised as close to the ligature as possible, cold water dressings are used, and the ligature is allowed to remain until the strangulated portion sloughs, when it, with the ligature, will be- come detached and pass off. Instead of using the ligature, I occasionally excise the pterygium near its base, after which I entirely cover the wound by drawing the conjunctiva together with sutures. 120 TEXT -BOOK OF OPHTHALMOLOGY. The advantage of this operation is the complete and thorough removal of the growth from the parts into which it has been imbedded, without the injury or superfluous removal of any normal tissue. DISEASES OF THE CORNEA. 121 CHAPTER VI. SECTION I. Diseast:s of the Cornea. CHE term corneitis signifies an inflammation of the cornea. Keratitis is a synonymous term and is oenerally applied to the different forms of inflammations of the cornea. Keratitis Interstitial Punctate. f Parenchymatous (dififuse) ^ Syphilitic i Strumous Vascular (Pannus) Ulcerative Suppurative Primary Secondary i Systemic IS Diffuse rcumscribed Interstttiai. Keratitis. In interstitial keratitis the entire cornea grad- ually assumes a chronic inflammatory condition without an inclination to the formation of pus or to ulceration. There is first a diffused grayish opac- ity of the cornea at the center, at first very slight, afterward very opaque, which gradually extends over the entire cornea, giving it a ground glass or steamy appearance, in which condition the iris and pupil are greatly obscured. 122 TEXT -BOOK OF OPHTHALMOLOGY. In very severe cases of instertitial keratitis the cornea presents a yellowish appearance, completely obscuring the iris and pupil. The degree of inflammation, photophobia, ble- pharospasm, lachrymation and pain varies, not with the amount of corneal opacity, but from a peculiar hypersensitiveness not explainable. There is a kind of pannus sometimes present in this affection which does not always come from the conjunctival blood vessels which run over the super- ficial surface of the cornea, but comes from branches of the ciliary vessels deep down in the corneal tissue. They are dullish red and named "salmon patches.'^ , Frequently the iris and ciliary body become im- plicated with the disease. This affection usually attacks both eyes, how- ever rarely at the same time, the interval being variable, from a week or more to months, or even a year. It occurs between the ages of three and fifteen usuall}^, although it may be seen earlier, and again it may occur much later. The duration of the affection is usually from four months to a year, or even longer, under the very best directed treatment. The effects of the disease are usually lasting, and distinct vision is scarcely ever attained. Inherited syphilis is the usual cause, although in some cases a specific history is wanting, and a gen- INTERSTITIAL KERATITIS. 123 eroiis diaf!:n()!sis would place the cause to ''want of vitality" or ''lack of |)roi)er noiirishiiH^nt.'- This affection is usually found in aniemic and weak persons, and the general health and hygienic conditions must first of all receive attention. Treatnwnt. — The medical treatment consists in a protracted course of alteratives, the principal of Avhich is the iodide of potassium. The iodide of potassium should always be pre- scribed in the saturated form and given in milk. Iodide of potassium given in this manner never ir- ritates the stomach, and children from two to ten years of age can easily tolerate fifteen grains three times a day. If for any reason the iodide of potassium cannot be tolerated, then inunctions of mercurial ointment in the groins and under the arm pits once a day until the mouth or gums begin to show its effects, when it should be discontinued until its effects have passed off. The syrup of the iodide of iron, and the hypo- phosphites of iron and strychnia, may be prescribed in the absence of the iodide of potassium, but there is no remedy so far as I know that acts so promptly as the iodide of potassium. I always give it in three or four tablespoonfuls of milk, and before meals. For adults I prescribe from one-half to one teaspoonful (30 to 60 grains) in milk, as for children. During the active inflammatory stage, a few 124 TEXT - BOOK OF OPHTHALMOLOGY. drops of a one per cent solution of atropine should be instilled into the eye two or three times a day in order to prevent adhesion of the iris to the lens capsule. The yellow oxide of mercury ointment in vary- ing strength, usually from one-half grain to one grain to the dram of vaseline, has always been recom- mended as a local remedy to the cornea in interstitial keratitis, but the difficulty in obtaining the prepa- ration free from irritating substances is almost im- possible, and I rarely, for that reason, prescribe it. Flushing the eye once or twice a day with a 1-5000 bi-chloride of mercury solution is much cleaner and reaches the affected part much better than is possible with the ointment. The fact is, no ointment should be applied to the conjunctival sac, as its ingredients scarcely over- come in contact with the affected part, for the reason that the vehicle is oleaginous, and is immediately carried off, with wdiatever it contains, by the secre- tions of the eye before it could possibly have very much, if any, effect. As children mostly suffer from this affection, they are inclined often to romp and play to fatigue. While exercise and fresh air are necessary, over- heating should be avoided. Good, healthy, nutritious food is essential. KERATITIS PUNCTATA. 125 KKKATniS Pl'NUTATA. Keratitis punctata is characterized by small spots on the posterior surface of tlie cornea, due to exudation of lymph from the iris and ciliary body. It is not a disease by itself considered, but the effects of an inflammation of the iris, ciliary body, or choroid. Keratitis punctata is a concomitant of serous choroiditis. It occurs very often in the sympathizing eye in sympathetic ophthalmia. It is usually of triangular form, the apex being near the pupil and the base below in the corneal peripher^\ The only part of the cornea that becomes af- fected in keratitis punctata is Descemet's membrane, and this, because of the irritating properties of the exudate which is thrown from the iris and ciliary body into the aqueous humor. Treatment. — As specific causes are almost cer- tain, and inflammation of the entire uveal tract, con- stitutional remedies are indicated. The general health in all cases must be im- proved. No local treatment is necessary unless the eye is seen during the exudation of the lymph and while there is inflammatory action; then the pupil must be kept dilated with a one per cent solution of atropine. 126 text -book of ophthalmology. Vascular Keratitis. Yascular keratitis is marked by a superficial vascularity and consequent opacity of the cornea. The vessels causing this vascularity, which in the normal state are invisible, become so large as to be plainly seen with the naked eye. The vessels thus making a pannus are contin- uous with those of the conjunctiva. When there are few of these vessels, and the opacity is not so great as to prevent their being seen separately, they are found to be very tortuous, much more so, than those which are met with in other inflammatory conditions of the cornea. The cause of pannus is generally a granular conjunctivitis, whereby the cornea is rubbed and thus inflamed by the diseased lids. It is also fre- quently caused by an entropion. In pannus there is always present pain, impair- ment of vision, photophobia and lachrymation. Sometimes the inflammatory action is very great; at other times it is slight. So with the pain; sometimes it is very severe, at other times it is almost absent, or simply an "uncomfortable feeling." The most dreaded complication is corneal ulcer, to which this condition of the cornea is very much inclined; should an ulcer appear, it is very apt to run a severe course, and endanger the eye, because of the vascularity of the cornea. ULCERATIVE CORNEITIS. 127 The treat nunt of i)aiinus is to ascertain the cause and remove it. If from granuhited lids, treat that affection in the most approved manner. If from entropion, an operation and removal of the hairs. Peritomy is not practical, and pus and jequirity inoculations need only be mentioned, to be emphat- ically condemned. Ulcerative Corneitis. A corneal ulcer is a morbid disintegration of the corneal tissue, attended by more or less inflam- matory action. There is an endless variet}^ of corneal ulcers, but for convenience of studj^ corneal ulcers may be clas- sified, according to their etiology, into the primary^ the secondary, and the systemic. Primary ulcers are usually confined to one spot, and are most frequently caused from some direct injury to the cornea, as an abrasion from a foreign body, or they may be due to a disturbance in the nutrition of the cornea, as in glaucoma, and in puru- lent conjunctivitis, where the chemosis interferes with the lymphatic circulation. Primary ulcers may be superficial or deep, ac- cording as they affect the superficial structures alone, or burrow deeply into the corneal tissue. Secondary ulcer of the cornea has its starting point in some other structure of the eve, most fre- 128 TEXT -BOOK OF OPHTHALMOLOGY. quently the conjunctiva, and passes over to the cornea. Secondary ulcers may also be superficial or deep. The serpigenous and herpetic forms belong to this class. Systemic idcei^ is due to some affection of the system at large, as scrofula, tuberculosis, or defective nutrition. The most common form of this is the phylyctenu- lar. Another less frequent form is the ulcus serpens. Subjectively, the first indications of a corneal ulcer are more or less pain, with a sensation of a for- eign body within the eye, an inflammation of the conjunctiva and lachrymation. Objectively, upon examination is found an opaque spot upon the cornea, the surface over which is somewhat raised and cloudy; this spot marks an infiltration in the corneal tissue. After the infiltration is formed the epithelium soon gives way over the spot, and is followed by a loss of substance of the corneal tissue; we have now a corneal ulcer. The first appearance of a corneal ulcer after the rupture of the epithelium, and breaking down of the corneal tissue, is the clouded or gray appearance of the walls of the ulcer. This condition is caused by the remaining infiltrate. If the infiltrate is thrown off, and the ulcer is soon cleansed, and the tendency of the ulcer is to heal at once, we have now what is regarded as a superficial, ulcer. ULCERATIVE CORNEITIS. 129 But if the infiltration extends en tiut-ssc, or in the form of slender stria into the body of the cornea, burrowing downwards into the corneal substance, it may distinguished as a deep ulcer. But if the infiltration extends in area, with well defined edges, or in the form of slender stria in dif- ferent directions in the transparent cornea, it is distinguished as a pr(}e of her- petic ulcer, before the vesicle bursts, does not avail much, and consists mainly in the use of cocaine to mitigate the pain. One important point in the treatment of corneal ulcer, whatever its character, is to paralyze the accommodation of the affected eye, not so much for its mydriatic affect, as to relive all strain. This is an important matter and should not be neglected. To accomplish this purpose, a few drops of a 1^ solution of atropine should be instilled into the eye once a day, unless there is a condition present indi- cating extreme mydriasis. After the vesicle has ruptured, treatment should be immediately applied to the abraded surface. This consists in applying, from a small cotton holder, a 1 to 1000 solution of the bi-chloride of mercury. This application should be made once a day. If, as it usually happens, the nostrils are impli- cated, the solution should be applied to the affected parts. There can be no substantial improvement as long as the eye is painful, and it must be relieved. The best and most lasting application I have found for this purpose is the following: R. — acid carbolic (pure), gtts, ii morphia sulphas, cocaine murias, aa, grs, iv glycerine, drs, ii aqua hamamelis, drs, vi. Mix and filter. A few drops into the eye when painful. 134 TEXT -BOOK OF OPHTHALMOLOGY. If there should be severe inflammatory action^ hot water applications should be em]3loyed in con- nection with the treatment indicated heretofore. The scrpigenoiis nicer is a creeping ulcer of the cornea, having a tendency to spread in a circular direction. It ploughs a narrow groove, usually, en- tirely around the circumference of the cornea, and thus disconnects its center from nutritive supply. The nutrition thus being cut off in the manner above described, the central portion of the cornea becomes opaque and frequently sloughs, and the vision is entirely lost, or reduced to the perception of light only. In some cases it attacks other parts of the cor- nea, but whatever part is affected, there is the ten- dency to the circular formation, these rings being sometimes small, and at other times will encircle almost the entire cornea as above described. Serpiginous ulcer is seldom opaque, and is not usually surrounded by an opaque border, and is thus easily overlooked. During the stage of sloughing there is no vas- cularization of the other parts of the cornea, but the appearance of new blood vessels, passing toward the ulcer from the conjunctiva, is the first indication of commencing repair. Strange to relate, these ulcers, however deep, are not usually accomj)anied with much pain, pho- tophobia, or lachrymation, the usual attendants of all inflammatorv conditions of the cornea. This in- ULCERATIVE CORNEITIS. 135 dicates that tlie iikei' is due to changes in nutrition caused by nerve lesion. Occasionally, however, there are exceptional cases where the pain is intense, and the photophobia, and its usual accompaniment, blepharosi)asm, is very severe. Serpiginous ulcer usually occurs in feeble, el- derly people, and creeps slowly but persistently to a completion of a circle, requiring, often, three or four weeks in making the round. Treatment. — As in herpetic ulcer, the most log- ical treatment in this form, is the application to the abraded surface of the bi-chloride of mercury solu- tion, 1-1000, once a day. The accommodation must be paralyzed, and pain must be subdued by the cocaine solution, or better, the solution of acid carbolic, morphia and cocaine, given under the treatment of herpetic ulcer. Much has been said in the praise of the galvano- cautery in the treatment of corneal ulcers, especially of this type, but I have not found it as effective in my hands as the treatment heretofore indicated. I have found, in this form of ulcer, that in old persons whose nutrition is impaired, the internal administration of a stimulant, as brandy, in liberal doses, is an important adjunct to the treatment. Systemic Ulcer, — This form of ulcer is due to some affection of the system at large, the most important, on account of its frequency of which, is the phlyc- tenular. 136 TEXT -BOOK OF OPHTHALMOLOGY. Phlj/ctenular Iceratitis consists of the formation of a small vesicle or vesicles on the cornea. These vesicles consist of a raised portion of the epithelium of the cornea, having the appearance of a raised blister, underneath which is a serous fluid. The vesicle is always accompanied with more or less inflammatory action owing to its situation, and the number of vesicles, as often several are found in close proximit}. The infiammator}' action is also greater when the vesicles are situated near the sclero-corneal border. In two or three days after the vesicle forms it bursts and its contents escape, and a small ulcer is formed, which is known as a phlyctenular ulcer. Phlyctenular ulcers are more liable to form at the periphery of the cornea, than near its centre, although they may form on au}^ part of the cornea, and also upon the conjunctiva. Those single ulcers which form at the periphery of the cornea are productive of great inflammatory action, and are often dangerous, as they are liable to perforate. Moreover, these peripheral ulcers may assume a serpigenous character, and creep along the surface of the cornea. This form is known as the vascular or herpetic ulcer. Phl^^ctenular keratitis is a disease particularly of childhood, although it may, and often does, affect adults. ULCERATIVE CORNEITIS. 137 Whether in childreu or adults, these ulcers usu- ally occur in persons of scrofulous habit and delicate constitution. Children who have inherited syphilis are partic- ularly liable to the phlyctenular ulcer. The pain and inflammation accompanying phlyc- tenular keratitis is variable; but there is a condition known as pUotophohla, an intolerance of light, which in some cases is so severe that the patient cannot stand the least light, and he seeks the darkest place and buries his head in the pillow or bed-clothes to prevent its admittance. This condition is not confined to children alone, but is frequent in adults also. With the photophobia, there is also another con- dition, known as hlepharospasm, or a spasmodic contraction of the lids. It is a usual accompaniment of photophobia. Photophobia and its concomitant, blepharo- spasm, are due to conjunctival irritation, superin- duced, usually, by corneal ulcer. An important matter is that the amount of con- junctival irritation does not regulate the intolerance to light, for it is frequently very severe from the slightest irritation, and vice versa. A phlyctenular ulcer in a child of strumous con- stitution is almost sure to bring about more or less photophobia. The cramp or spasm which causes the blepharo- spasm starts in a reflex manner from the sensory 138 TEXT -BOOK OF OPHTHALMOLOGY. facial nerves. This is easily demonstrated, as pres- sure upon the affected nerve often relives the spasm at once. Treatment. — The treatment of phlyctenular kera- titis in children is difllcult because they are usually unmanageable, and it is often impossible to see the eye without physical force, or the use of an an«es- thetic. I prefer to give an ansesthetic when there is much resistance, especially for the first examination of the eye, for the reason, that should there be a deep ulcer, great resistance might cause perfora- tion, which could otherwise be prevented. In the case of an adult, a few drops of a four per cent solution of cocaine in the eye will render it capable of being very easily examined. The ulcer should be thoroughly cleansed (after the eye has been cocainized) with a small pledget of absorbent cotton placed upon the point of a small cotton holder. The cotton should be moistened in a 10-grain solution of boracic acid. After the ulcer has been thoroughly cleansed in the manner described, its surface should be touched with a stimulating antiseptic solution. I have used the following with great satisfaction: ULCKRATIVR CORNEITIS. 189 R, chloride zinc, j^rs i, cocaine mnrias, morphia snlphas, aa grs iv, acid carbolic, gtts v,. glycerine, drs ii, aqua rosa, drs vi. Mix and filter. Apply with a small cotton applicator to the walls of the ulcer once a day. After the ulcer commences healing, it will not be necessary to use it so often, but it should be very carefully applied once a day until it is pretty well healed. This application is very soothing, especially where the ulcer is painful. In corneal ulcer, no matter what its character or where situated, the accommodation should be paralyzed with atropine. The reason for this is, that the eye should be relieved from all strain. It has been suggested that the local effect of atropine upon the ulcer is beneficial, but I am sure that this is not the case, but the benefit comes from the loss of accommodation, and thus having the eye in a state of rest. There is a rule however to be observed with regard to deep ulcers: When a deep ulcer is situated at or near the center of the cornea, and we are fearful of perfora- tion, the pupil should be widely dilated, and its edges kept as far away from the ulcer as possible, in order 140 TEXT -BOOK OF OPHTHALMOLOGY. to prevent an intrusion of the iris into the wound, should the cornea rupture. On the other hand, shouUl the ulcer be situated near the periphery of the cornea, the pupil should be contracted with eserine for the same reason. The patient should always have a soothing lo- tion at hand to relieve the suffering should the eye be- come painful. An eye can not improve as long as it is painful. To allay the pain I use something like the follow- ing, which can be varied to suit individual cases: K, hydra st in, gr, ss acid carbolic (pure), gtts, ii, cocaine murias, grs, viii, glycerine, drs, ii, aqua hamamelis (dist'd), drs, vi, Mix and filter. A few drops should be instilled into the eye whenever it becomes painful, and continued, as often as every five minutes, until the pain ceases. The combined anaesthetic effects of the cocaine and carbolic acid in corneal ulcer, of whatever char- acter, is very advantageous because of its lasting effects. The general treatment in phlyctenular keratitis should be conducted in accordance to the cause. Invigorating measures, such as exercise in the open air, nutritious food, salt water baths as warm as can be borne, and such other remedies as are best adapted to give tonicity should be resorted to. The SUPPURATIVE KKRATITIS. 141 s^Tup of the iodide of iron, cod liver oil, sulphate of quinine, and iodide of potassium ai*e indispen- sables. It is important that the nasal cavities should be examined and any catarrhal condition of the nose or throat should be treated. Photophobia is one of the most annoying com- plications of phlyctenular ulcer, and may continue long after all inflammatory actions have subsided. I have often relieved photophobia in adults by the hypodermic injection of morphia over the supra- orbital nerve. I would not however advise its use in children. In young persons, in severe cases, the speediest and most permanent relief can be attained by can- thotomy. How does canthotomy relieve blepharospasm? The conjunctiva of the lids is richly supplied with sensory filaments from the fifth pair of nerves. Irritation of the peripheral extremities of these nerves, by a reflex action causes cramp; pressure increases irritation; canthotomy diminishes the pressure, and therefore relieves the cramp. I have frequently known canthotomy relieve this distressing condition in two or three days, that Jiad resisted local treatment for months. Suppurative Keratitis. Suppurative kr rat if is is diffused or circumscribed. In the diffused form the cornea loses its bril- 142 TEXT -BOOK OF OPHTHALMOLOGY. liancy, becomes steamy, assumes a grayish-white appearance, followed rapidly by a yellowish tint, which indicates the formation of pus between the lamellae. The epithelium now disappears, and the lamel- lae become separated and detached by the forma- tion of pus. When there is an extensive formation of pus and loss of corneal substance, the intra-ocular pressure is so ^Teat that the parts are often unable to resist it, are pushed forward, and cause considerable bulg- ing of the cornea and often perforation. Suppurative keratitis, whether diffused or cir- cumscribed, is always an acute affection, following very rapidly what was often thought to be simply a slight serous conjunctivitis. Although suppurative keratitis may be the re- sult of a corneal traumatism, such as a blow or other injury upon the cornea, or of an operation upon the eye involving the cornea, as for cataract; sometimes however, a suppurative keratitis is due to a puru- lent conjunctivitis, and is caused by the corneal nu- trition being interfered with from the conjunctival swelling and accompanying chemosis. Suppurative keratitis may be precipitated with- out any known injury to the eye, or any known cause whatever, but when it occurs spontaneously, it is usually in persons of scrofulous habit, or in old people whose nutrition is not good. Circumscribed keratitis is first indicated by an vSrPPURATIVE KKRATITIS. 143 opaqiu' whitish spot upon some part of the cornea. The central part of the spot soon changes its color to a yellowisli tint which indicates the existence of pus. If the pus formed is near the surface, the outer layers of the cornea break down and the pus is dis- charged externally, and an ulcer is thus formed. Should the pus be formed deep in the cornea, it breaks through the layers into the anterior cham- ber in the aqueous humor. In this case the pus be- ing heavier than the aqueous humor, it settles to the bottom, and forms what is known as hypopyon. The layers of the cornea between which the pus is situated are frequently separated to such an ex- tent that the pus gravitates toward the bottom of the cavity and gives it the appearance of an hypo- pyon. This condition is known as onyx, and is usu- ally easily distinguished from hypopyon. In hypopyon the upper level of the fluid is sharply defined, and is in a horizontal line, especially if the patient has been in an erect position for a short time. It shifts its position if the patient inclines the head from one side to the other. On the other hand in onyx the upper portion is usually irregular. It is sometimes necessary, how- ever, to resort to focal illumination in order to estab- lish the diagnosis. Treatment. — In the treatment of suppurative keratitis, the first matter of importance is to dilate the pupil. This is essential for two reasons: the first 144 TEXT -BOOK OF OPHTHALMOLOGY. being, that the eye should be kept in a state of rest, in all inflammatory actions, if possible; then severe corneal inflammations always complicate the iris, and it is well to have the pupil so well dilated that there can be no adhesions of the iris to the lens capsule. I am sure that a well dilated pupil places the iris in the very best possible condition to resist inflam- mation. There can be very little exudation of serum or lymph from an iris whose pupil is extensively dilated, hence occlusion of the pupil, and iritic ad- hesions, the usual results of severe inflammatory conditions of the eye, are reduced to the minimum. In the incipiency and during the active inflam- matory stage of suppurative keratitis, warm water fomentations, as hot as can be borne, should be ap- plied to the eye, and kept up as long as an hour at a time, two or three times a day. This process will often establish and maintain the circulation to such an extent as to cause resorption and prevent sup- puration, if resorted to at an early stage. After the fomenting is completed the eye should be covered with a slight compress of dry, heated cotton-wool. A light bandage may be used to keep it in iDlace. . , Should the abscess break into the anterior chamber, and an hypopyon be formed, if extensive, the operation of piwacentcsis should be made, by makinj>- an incision in the lower part of the cornea,. CORNEAL ULCERS. 145 near its peripliory, and letting out the pus. On the other hand, if there is not much pus, and it is thiu, it will absorb without doing any injury. If the abscess forms near the surface, it should be punctured, its contents emptied, the walls of the sac treated antiseptically as in corneal ulcer from an^^ cause. If the general health of the patient is al, fault, it should be corrected, as the conditions demand. General Considerations of Corneal Ulcers. In practice we often meet with cases of cor- neal ulcer where it is impossible to draw a line of demarkation between the different forms already considered, but this cannot, from a practical point of view, be considered of very great importance, since the treatment resolves itself into a very few well established principles. There is no affection of the eye more tedious to treat than corneal ulcer, no matter what the cause, nor however uncomplicated it may be, for it requires so great a length of time to complete its course. An ulcer may be superficial or deep; the pain may be very slight or the patient may suffer severely ; there may be much inflammatory action, or the in- flammation may not be very marked; there may be severe photophobia and blephorospasm, or not; the .ulcer may be very large, covering a great portion of the cornea, or it may be very small, scarcely notice 146 TEXT -BOOK OF OPHTHALMOLOGY. able ; it may be central, or it may occupy a point near the periphery. Such are the varied conditions of corneal ulcer. Superficial ulcers are usually more painful than the deep, hence severity of pain, in corneal ulcer, is not indicative of great danger to vision. Another thing in regard to corneal ulcer is, that those situated near the sclero-corneal border are usually much more painful than those which are situated near the center. All ulcers that are not of traumatic origin, are to be regarded as systemic, and the general health must be regarded as a matter of great significance in this affection. A corneal ulcer, however good the recovery may be, always leaves the cornea more or less impaired, no matter whether it has had its seat in the center of the cornea, or at its periphery, from the simple fact that it leaves more or less of an opacity. Another matter with regard to corneal ulcer is this, there always remains therafter the tendency for a recurrence. This is particularly true with re- gard to phlyctenular ulcer, and I have observed it very often in the other forms also. The most destructive ulcer to the vision is the perforating, whether it is central or not, for when the ulcer perforates, the iris or the lens, or both, be- come complicated. Even if the ulcer is deep, and there is no perfor- ation, the contour of the cornea is changed, which. CORXKAL ULCERS. 147 tof^etlier with the resiiltin,i>- opacity, causes very de- fective, if not compute loss of vision. There is another and a greater danger from a perforating ulcer: the iris is liable to become dragged into the wound, and to become permanently adhered to the cornea, in which event, by its teasing and pulling upon the ciliary body, in its efforts to dilate and contract, it may be the cause of generating a sympathetic ophthalmia. Should the corneal wound be large, a consid- erable portion of the iris, as well as the crystalline lens, may become prolapsed into the opening. In this case, as soon as the inflammatory action has somewhat subsided, the eye should be removed, for ciliary iritation is liable to occur and lead to sym- pathetic ophthalmia, and the loss of the other eye. No operation for the removal or the reduction of the staphyloma should be entertained when the vision is irreparably lost, because the danger of exciting a sympathetic inflammation is so great that a very little time lost in the effort to retain the in- jured eye may be, and often is, fatal to its fellow. One thing we should always observe, and it will bear repetition: the accommodation should be par- alyzed immediately upon the discovery of a corneal ulcer. This relieves some strain, and thereby pre- vents a certain amount of inflammatory action. This should be observed in most all inflammations of the eye, except where there are evidences of glau- coma, but in corneal ulcer, and in irititis it is par- ticularlv indicated. 148 TEXT -BOOK OF OPHTHALMOLOGY. The position of the ulcer, especially if it is deep, is another matter of very great importance, espe- cially should there be danger of its walls giving way. If it is central the pupil should be dilated, and the pupillary border of the iris kept as far from the wound as possible. If on the other hand the ulcer is near the periphery of the cornea, the pupil should be contracted for the same reason. This can be ac- complished, with a solution of eserine, even while the accommodation is relaxed under the influence of a mydriatic. If there is severe inflammatory action in con- nection with the ulcer, the eye should be bathed with hot water, as warm as can be possibly borne, for as much as an hour at a time. This should be done three or four times a day. As the iris is liable to take on inflammatory' action in case of corneal ulcer, especially if the latter is situated near the periphery, we must not allow an exudation of lymph to bind the iris to the capsule of the lens, or to fill the pupillary space, if it can be prevented. In this case the iris must be kept as widely dilated as possible, even should the ulcer be deep, for a perforation of the cornea at its border is not nearly so liable to occur as when it is more cen- tral, and does not subject the eye to so much danger as the iritis. One of the most annoying complications in cor- neal ulcer is the photophobia and blepharospasm, but we must remember that this bears no relation STAPHYLOMA. 149 to tlic extent of tlie ulcer, for the most obstinate cases have Ixnni the result of a very slight affection of the cornea. The treatment is simple and usually very effect- ive: a canthotomy, and the application of simple rem- edies to relieve any existing conjunctival irritation. SECTION II. Staphylo^ia. Staphyloma may be defined as a protrusion of the cornea or sclera, due to inflammatory action. Corneal staphi/loma consists of a prolapse of the iris through a wound of the cornea, generally the result of corneal ulcer. Scleral staphyloma consists of a thinning of the scleral tissue, which gives way before the intraocular pressure. There are two forms of scleral staphyloma, viz. : anterior scleral staphyloma and posterior staphyloma. Anterior scleral staphyloma occurs over the region of the ciliary body. This condition is generally due to s.yphilis. Posterior staphyloma of the sclerotic occurs in the posterior segment of the sclera. This condition is usual in m^^opia. The treatment of corneal staphyloma, especially if there is much protrusion of the cornea and iris, is enucleation. 150 TEXT -BOOK OF OPHTHALMOLOGY. It is now generally conceded that those opera- tions which consist in the removal of a whole or part of the corneal tissue, together with the pro- truding iris, and drawing the parts together with . sutures, are not practical, but are often the cause of sympathetic inflammation. When an eye is so badly injured from a staphy- loma or any other cause that its vision is irreparably destroyed, especially if the iris and ciliary body are involved, enucleation is not only necessary, but urgent. The same may be said of anterior scleral staphy- loma, because the ciliary body, which is always more or less involved, is the starting point for all cases of sympathetic ophthalmia. I am very sure that exceptions will often be taken to the removal of an eye, although irreparably blind, especially if the staphyloma be small, for by a system of puncturing the anterior chamber to al- low the aqueous humor to escape, and bandaging the eye with a firm compress, the staphyloma may become reduced so much as to preserve the normal contour of the cornea; but the elements which ex- cite sympathetic ophthalmia, that is, the adhesions of the iris in the corneal wound, still exist. There is a form of staphyloma known as conical cornea, or transparent anterior staphyloma, which consists of a bulging forwards of the central por- tion of the cornea. This condition should always be looked for in WOUNDS OF THE CORNEA. 151 near-sio'hted individuals, for it is often mistaken for myopia. • Conical cornea generally appears at from twelve to twenty years of age. It progresses steadily for three or four years, after which it usually remains stationary. The cause of conical cornea is not fully estab- lished. Whether it is due to a latent inflammatory condition of the cornea, causing softening near its center, or to an iutra-ocular tension, producing a yielding of the cornea, at this its thinnest portion, is not fully decided. Eest is the only treatment, and keeping, the eye fully corrected with regard to its refraction. The various operations of trephining and excis- ing the cornea, have not been generally accepted. Such operations are very delicate and should be re- sorted to wath great caution. Wounds of the Cornea. Wounds of the cornea, whether superficial or penetrating, are of great importance. However superficial a wound may be, if nothing more than a simple abrasion, it is liable to set up severe infiam- matory action, with suppuration of the cornea and loss of vision. This is not so much from the extent of the injury, as from the introduction of septic mat- ter into the wound; for this reason the greatest care should be exercised in dressing the wounds, 152 TEXT -BOOK OF OPHTHALMOLOGY. thorough asepsis should be practiced, and such anti- septics emplo^^ed as are indicated. In penetrating wounds of the cornea, the wound shoukl be asepticallv dressed, and the iris, if protrud- ing and not wounded, should be returned, but if mutilated should be excised. Great care must be taken that no part of the iris be allowed to remain within the lips of the wound. Atropine solution should be instilled into the eye, and a light compress secured by a bandage. If the penetrating wound is deep and involves the deeper structures of the eje, as the lens, ciliary body, etc., treatment will be more complicated. When the lens is wounded, it frequently swells to such an extent as to cause suppurative inflamma- tion, and consequent loss of the eye. Fistula of the Cornea. Fistula of the cornea sometimes follows wounds of the cornea either from an injury or an operation upon the eye involving the cornea, or from a pene- trating corneal ulcer, in which case there is a con- stant drainage of the aqueous humor. This condition keeps the eye continually irritated, and it cannot be used to any advantage while in this state. Treatment consists in keeping the pupil contract- ed if the fistula is near the edge of the cornea, and dilating it, if it is near the center, for the purpose of keeping the pupillary border as far from the fistula ARCUS SENILIS. 153 as possible, so as to avoid its intrusion into the open- ing. At tlie same time, the edges of the fistula should be freshened with fine forceps in order to excite the process of healing, after which the com- press bandage should be applied over the eye. Arcus Senilis. Arcus semlis, known also as gerontoxon, is a hyaline or fatty degeneration of the corneal cells, appearing a little inside the margin of the cornea, and usually extending entirely around it, although more prominently^ marked at the upper and lower borders. As a general thing arcus senilis is an affection of age, but it is occasionally met with in youth. This affection is not of serious import, and no functional changes are caused b}- it, the cornea not losing any of its vitality because of its presence. Wounds on the arcus senilis heal as readily as on the clear cornea. There is no treatment for arcus senilis. 154 TEXT -BOOK OF OPHTHALMOLOGY. CHAPTER VIL Injuries and Diseases of the Sclera. yy ■OUNDS of the sclera may vary from a fl K I minute abrasion to a perforation or ^^^^r rupture. In perforating wounds of the sclera, there is great danger of injury to the internal coats of the eye together with septic infection. There may also be a loss of the vitreous humor, which if great, renders the prognosis very unfav- orable. Small abrasions usually heal rapidly, but in deeper wounds where the choroid and retina are im- plicated, the prospects of rapid healing and unim; paired vision are unfavorable. Treatment. — Small abrasions usually heal with- out treatment. When the sclera has been injured so as to make an open wound, the eye should be cleansed with an antiseptic solution. If any of the choroid protrudes from the wound, it should be removed with the scis- sors and the edges brought together with fine sutures. If the wound has been large, the conjunctiva should always be sutured after bringing the edges of the sclera together. A suitable dressing should be placed on the eye, and when soiled fresh ones reapplied. If septic material has been introduced by the SCLERITIS. 155 perforating;' instrument, there will probably be a for- mation of pus and the eye entirely destroyed. In this event, timely enucleation should be resorted to, in order that the other eye may not, throuj^h sympa- thy, become involved. SCLERITIS. Scleritis is an inflammation of the sclera. Episcleritis is an inflammation of the superficial layers of the sclera. There is hyperaemia of a portion of the sclera and the vessels of the conjunctiva immediately above the inflamed part of the sclera become injected. The inflamed portion has a reddish-blue hue. The pain accompanying scleritis varies accord- ing to the severity of the affection. The duration of scleritis is usually from ten days to a month, although some cases become chronic. Scleritis is most frequentl}^ seen in persons af- fected with gout, syphilis, rheumatism or scrofula. Treatment. — The treatment consists in hot water fomentations, and where found in conjunction with syphilis, rheumatism, gout or scrofula, general rem- edies for such diseases exhibited. The eyes should be protected from the cold and the patient warned not to strain. Astringents are irritating and should not be used. 156 TEXT -BOOK OF OPHTHALMOLOGY. CHAPTER VHL SECTION I. DISEASES OF THE IRIS. Ipjtis. c HE term Iritis signifies, as its name imports, an inflammation of the iris. For convenience of study, iritis may be divided into the following forms: ' Serous. Plastic. Iritis ■{ r Non- suppurative. I Parenchymatous -{ Suppurative or [ [ Purulent. In serious iritis there is an exudation of serum from the blood contained in the iris and ciliary hodj into the chambers of the eye. This exudation comes mostly from the posterior surface of the iris and the the anterior portion of the ciliary body. In serous iritis the anterior chamber is often very noticeabh^ deepened. This is owing to an ex- cessive secretion of aqueous humor and serum, and also to an obstructed outflow of the aqueous humor into the canal of Schlemm, consequent to the swell- ing of the fibres of the ligamentum pectinatum, which guard the entrance to that cavity. The increase in tension in serous iritis is due to DISEASES OF TPIE IRIS. 157 the above conditions; that is, to the increased inflow of lymph and serum and their obstructed outflow. In serous iritis the pupil is sluggish in its action and somewhat dilated. In serous iritis the exudation is mostly serum, and not so much lymph. Therefore the tendency to the formation of plastic exudations and adhesions is not so great as in otlier forms of iritis. Opaque dots frequently form, in serous iritis, upon Decemet's membrane. This condition is known as keratitis punctata, and is caused b}^ small coagu- lable particles which are formed in the lymph exu- dation, and which adhere to the inflamed endothe- lium of the cornea. These deposits settle at the lower quadrant of the posterior surface of the cor- nea, in a prismatic shape, the base of which corre- sponds to the lower margin of the cornea, the apex being directed upw^ard toward the pupil. These de- posits are frequently overlooked, because they are so excessiyeh^ minute. We should, therefore, in every suspected case of serous iritis, look for them with a strong magnifying glass. The cornea in serous iritis becomes cloudy and loses its brilliancy. The aqueous humor in serous iritis is always somewhat cloudy, although not so much so, as in the plastic form. This is on account of the coagulable deposits which are in the exudation. As there is not so much lymph deposited in this form as in the plastic, therefore there is not so much coagulable deposit. The inflammatory action in serous iritis is not 158 TEXT -BOOK OF OPHTHALMOLOGY. active, but is subacute or chronic, and of a marked recurrent type. At first the attacks are but slight and of short duration, lasting from two weeks to a month, and then gradually subsiding; then in the course of time another attack comes on, generally of increased severity. The increased tension of the globe becomes a more prominent feature in each successive attack. In some cases of serous iritis profuse hemor- rhages into the aqueous chambers occur from the bursting of the distended blood vessels of the iris. Serous iritis is always accompanied by some inflammatory action, but it is not so pronounced as in the plastic form. We have the ciliary injec- tion, pain, photophobia and lachrymation. In some rare cases, most of the above symiDtoms are absent. The diminished vision in serous iritis is due to turbidity of the aqueous humor or the exudation in the pupil, or in the cavity of the vitreous. In serous iritis the ciliary body, especially the anterior portion, is complicated. There is no direct proof of this in slight affections of the ciliary body, because it can not be seen directly, but symptoms of positive evidence of its involvement to any great extent are always present, viz: 1st. There is always tenderness on the slight- est pressure in the ciliary region. 2nd. Where the inflammatory symptoms are quite marked, there is swelling or oedemia of the upper lid. Serous iritis may, at any time, take on the plas- tic form, or go on to suppuration. PLASTIC IRITIS. 159 Although rheumatism and syphilis have been regarded as the usual causes of serous iritis, I feel that most cases can be referred to some ocular defect which causes strain upon the ciliary body, such as the errors of refraction. Outside of its being the result of an injury, directly or indirectly (sympa- thetic ophthalmia), I am confident that this is often the case. The treatment in serous iritis is atropine. The pupil, if possible, must be kept dilated. Eyen in serous iritis, where there is usually a small exudation of lymph, the iris may be bound down to the lens capsule, so that the pupil will not be influenced until several applications of the atro- pine have been made. In such cases a few drops of a one per cent solution of atropine should be in- stilled into the eye every hour until the pupil dilates, or in the event it does not dilate, until the inflamma- tory action has subsided. Plastic Iritis. Plastic iritis is the most common form of iritis and is due mostly to rheumatism and syphilis. There are, however, cases of plastic iritis that can not be traced to either of the above affections, which are often attributed to climatic changes. In this form of iritis there is an exudation of plastic lymph from the blood vessels of the iris into the aqueous chambers. In plastic iritis there are always inflammatory symptoms, often of a marked character, such as pain, contraction of the pupil. 160 TEXT -BOOK OF OPHTHALMOLOGY. conjunctivitis, circum-corneal injection of the ciliary vessels with elevation of the linibus conjunctiva and more or less chemosis. The pain accompanying plastic iritis is not so severe as in the serous and other varieties, in fact there are cases of what is termed by some authors "quiet iritis," where it is said there is no appreciable evidence of inflammation, in which plastic exuda- tions had been thrown out and adhesions formed without the patient suffering any inconvenience, but gradual loss of vision. These cases of iritis are of syphilitic origin, and I think a close examination of the eye during the exudative process would have shown evidence of inflammatory action. Owing to the inflammatory condition of the eye, tiie cornea loses its brilliancy and becomes slightly steamy. This is caused by the involvement of the epithelium in the general inflammation. The color of the iris changes for the same rea- son; that is, the involvement of the endothelium covering the anterior surface of the iris. It also changes the color because of the cloudiness of the aqueous humor and cornea, and the engorgement of the blood vessels of the iris itsell As in all cases of iritis, the color of the iris changes from a blue to a greenish hue, and from a brown to a reddish brown. The amount of plastic exudation varies usually as to the cause of the iritis, and also the degree of general inflammation. If the iritis is due to syphilis, the amount of lymph thrown out is larger than in the other forms. PLASTIC IRITIS. 161 This is an important point in the difTerential diagnosis of the iritis due to syphilis, and iritis due to rheumatism. Another matter, the patient doc^s not usuall}^ suffer so much pain when the iritis is due to s^^philis, as when it is due to rheumatism. In iritis, especiall}, if the rheumatism is of the chronic variety the pain is usually very severe. The amount of exudation is not always in con- formity with the degree of inflammation, as a very slight inflammation may be accompanied by an exuberant exudation, and vice versa. The anterior chamber of the e^'e is always dee^j, as in the serous variety, owing to the amount of exu- dation thrown out; the increase being so great some- times as to cause an increase in the intra-ocular tension. It is often very difficult to diagnose a plastic from a serous, or what is termed a simple iritis; happily this does not complicate matters, as the treatment for all forms does not materially differ. The most dangerous complication in plastic iritis is adhesions of the iris to the lens capsule (post en ior synech \a). In some cases of iritis the quantity of plastic lymph thrown out is enormous, and not only a part of the pupilliary border of the iris may become adhered to the lens capsule, but the whole border may become attached (seclusion of the pupil) and the pupillar}^ space may be completely filled with the exudate (occlusion of the pupil). The first essential in the treatment of iritis, 162 TEXT -BOOK OF OPHTHAIvMOLOGY. from whatever cause, is dilatation of the pupil, and especially is this necessary in the plastic forms. Atropine is indicated at the earliest possible moment, and its use should be continued until all of the adhesions are broken. If there are extensive attachments of the iris to the lens capsule a few drops of a one per cent solution of atropine should be instilled into the eye as often as once an hour, as long as the adhesions last, or until the inflammation subsides. If the adhesions are not so extensive, the appli- cation may not be made so often, two or three applications a day being sufficient in many cases. With this treatment fomentations of water as warm as it can be borne, especially if there is much inflam- matory action present. My experience has been that there is no advan- tage in a stronger solution of atropine than the one per cent, and that its maximum effects can be as promptly and as thoroughly obtained by its fre- quent application, as by that of a stronger solution. It can be used as often as every fifteen minutes for three or four hours each day in order to detach recent extensive adhesions. Old adhesions of any great extent cannot be broken by the use of any mydriatic, and it is in re- cent cases only that we can hope to effect any relief from the use of atropine. In plastic iritis internal medication is always essential. If it has been caused by syphilis, then the iodide PARKXCHVMATorS IRITIS. 163 of potassium or merciiiy, preferably, the iodide of potassium. I give the iodiiU^ of potassium in the form of a saturated solution, and advise the patient to take it in milk. From fifteen drops to one teaspoonful of the saturated solution in three or four tablespoon- fuls of milk before meals for the adult. I have never seen this treatment disagree with the most irritable stomach, but on the other hand I have known many irritable stomachs benefitted by its use. When we know the iritis to be of syphilitic origin, in addition to the iodide of potassium, inunc- tions of mercur}^, in the form of the mercurial oint- ment, rubbed in the arm pits once a day until its effects are demonstrated by a cessation of the in- flammatory action, or by its constitutional effect upon the mouth or the gums. Pabenchymatous Iritis. Parenchymatous iritis is presented in two forms, the nonsuppurative and the suppurative. In xjarench^'Uiatous iritis there is the formation of well defined masses upon the iris. These masses are termed nodules or condylomse. These nodules vary in size from the smallest pinhead to formations almost filling the entire an- terior chamber and encroaching on the cornea. The color of the iris changes materially at the affected part and becomes reddish-yellow or yel- lowish-green. In the nonsuppurative variety the inflammation 164 TEXT - BOOK OF OPHTH ALMOIvOGY. terminates by resolution, in which ease the nodule^ gradually disappears without abscess or injury of the tissue involved. This does not often occur, as cicatrices form in the iris substance, causing irreg- ularities in the shape of the pupil, or displacing it. Extensive adhesions are also liable to form between the iris and lens capsule. When the nodule is extensive I have known, in a few instances, of adhesions between the iris and posterior surface of the cornea. In the suppurative form the pus gravitates to- the bottom of the anterior chamber and forms an hypopyon. Other portions of the eye frequently contribute to the formation of pus at the same time the iris is involved, especially the posterior elastic lamina of the cornea. As this membrane is a continuation of that which covers the anterior surface of the iris, it is readily seen how easily it may in like manner become implicated. Besides affecting the posterior lining membrane of the cornea, the suppurative form occasionally ex- tends to the surrounding tissues of the cornea, the ciliary bod}^, the choroid and the vitreous. These nodules are usually situated near the pu- pillary border of the iris, occasionally at its peri- phery, but rarely in the body of the iris. The cause of parenchymatous iritis is mostly syphilis. GENERAL CONSIDERATIONS OF IRITIS. 165 SECTION II. General Coxsideuatio.ns of Iiutis. Inflammation of the iris per .sr is rare, for the reason that the uveal tract (iris, ciliary body and choroid) are supplied by the same blood vessels, and form one continuous whole. It is thus readily comprehended how all these parts may be affected at the same time. Especially is it the case with the iris and ciliary body, for either one is more liable to inflammatory action than the choroid. The first and only symptom usual in the begin- ning of an iritis, from whatever cause, is a conjunc- tival irritation, wth its concomitant, a serous, or watery dscharge from the eye. It is no great wonder that many physicians mis- take this for a simple conjunctivitis, and prescribe some simple remedies as mild astringents, which within themselves are harmless. But the time lost is of serious moment, as frequently during this seem- ingly slight inflammatory condition of the eye, plas- tic lymph is thrown out, and the iris is often firmly adhered to the lens capsule, and the pupillary space is frequently occluded before we are aware of the real nature of the affection. As so many eyes are lost in this manner, I desire to invite attention to a few simple points that will assist us in determining when we have an iritis. First. When we examine an eye that is in- flamed, no matter what the history of the case, we should carefully note the color of the iris, and com- 166 TEXT -BOOK OF OPHTHALMOLOGY. pare it with its fellow. This is very important, es- pecially if both eyes are not alike affected, which is not usual in iritis. A pale blue iris becomes a dark blue or a green- ish-blue in iritis, and a gray iris becomes reddish- brown. If both eyes are inflamed, it is difficult of course to gain much information from this examination. Second. Note the action of the pupils to light and shade. Close both lids, and then open one of the eyes to the light. Watch the action of the pupil, and ascertain if, at the first exposure to the light the pupil was dilated, and if it at once contracted wnen the light entered the eye. This being the case, iritis can, as a rule, be excluded. On the other hand if, after both eyes have been shaded, the pupil remains stationary, and upon ex- posure to the light it is difficult to determine whether it contracts, or we can observe no perceptible move- ment of the pupil to the effects of light and shade, then w^e must expect iritis. It must be remembered that the pui^il is not always contracted in iritis. In the serous form it is always dilated, but not to a great extent: but the inactivity of the pupil is as persistent in this form as in the plastic. If the iritis is due to a traumatism, the cause should be removed in case it continues to exist; if a foreign body is embedded in the iris, it should be removed; if a portion of the iris is intruded in the wound, it should be liberated or removed, and if genp:ral considkrations of iritis. 167 contused, it sliould be excised; if tlic^ lens is dis- dislocated, it should be removed, and if llie .ulobe is irreparably wounded, it should be enucleated with- out delay. There is no advanta<>e in retaining a badly la- cerated globe, and esijecially if there is any evidence of extraneous matter within. The retention of a badly wounded eye is often the cause of total loss of vision of its fellow through sympathy. To return to the serous and plastic forms of iritis, as a local treatment atropine is first, hist, and always. As I have indicated heretofore, there is no ad- vantage in a stronger solution of atropine, than a 1 per cent. If the indications are urgent, then its frequent use; if not so significant, then its applica- tion should be regulated accordingly. Besides atropine, we have duboisin, a more pow- erful mydriatic, that has been used in extreme cases, but as it is very liable to produce toxic symptoms, it should not be resorted to, except by one who has had some experience in its use. For myself, I have had such experience with duboisin, that I am content to be satisfied with the medicinal virtues of atropine. Whether in the serous or plastic forms of iritis, internal treatment is of paramount importance. If due to rheumatism or syphilis the iodide of potas- sium is alike indicated. I ahvays use the saturated solution, and give it in milk. Whenever there is an exudation of lymph, whether serous or plastic, the iodidf^ of ])otassium is 168 TEXT -BOOK OF OPHTHALMOLOGY. adiiiissable. If the lymph is more of the serous character, the dose need not be so large, but if of the plastic form, then it should be pushed to its utmost extent. While morphia and other narcotics are permis- sible in the general treatment of iritis, especially if the pain is severe, their use is often detrimental, in that they check the secretions and derange the di- gestion. It may not be generally known, but it is a fact nevertheless, that the use of the iodide of potassium, as heretofore indicated, will relieve the pain and give rest, in iritis, when narcotics will not, and without disturbing the system at large. It is especially in- dicated in the supra-orbital neuralgia, which is so frequent an accompaniment of iritis, especially of the serous variety. Salicylic acid and salicylate of sodium, which- were in former years so highly extolled, especially in that form of iritis due to rheumatism, need only be mentioned to be condemned, as their effect in disturbing the digestion is too well known to permit their employment. The old methods of cupping, leeching and blis- tering are of ilo value in iritis, and the patient should not be subjected to any of these antiquated pro- cedures. Poultices are valueless, and for aseptic reasons alone should not be resorted to in any affection of the eye. During the active inflammatory^ stage of plastic or purulent iritis, the application, over the eye^ of GENERAL CONSIDERATIONS OF IRITIS. 169 hot watia* foiiioiitatioiis is IxMielicial, as well for its sedative effects, as to hasten absorption. Tlie ch)ths shouhl be Avnni<> out of warm water, as hot as can be boriu% and ai)plie(l as oftc^n as every five minutes for an hour at a time, as often as two or three times a day. Cocaine if applied frequently will affect the deeper structures of the eye, and is very beneficial in conjunction with atropine when the eye is painful. I would recommend in such cases equal parts of a one per cent solution of atropine and a four per cent solution of cocaine. A few drops in the eye every five minutes until the pain is relieved; after- wards as often as necessary to relieve the pain and keep the pupil dilated. Paracentisis of the anterior chamber should not be performed, unless the chamber has an accumula- tion of pus. It is a dangerous procedure to make an opera- tion upon a badly inflamed eye, and should not be resorted to only as a deniier rcssort. Iritis is more common in adults than in chil- dren, and for that reason great care must be taken in diagnosing the affection from glaucoma, the latter being a disease usually of advanced life. The application of atropine in glaucoma is dan- gerous, and very liable to set up a destructive inflam- mation. The conjunctival sac should be flushed two or three times daily with an aseptic solution, as the bi- chloride, 1-5000, or the boric acid solution. This is particularly necessary if there is a high stage of in- 170 TEXT -BOOK OF OPHTHALMOLOGY. flammatory action. This procedure is highly bene- ficial, not onl}' in iritis, but in any inflammatory con- dition of the eye, as the conjunctival sac is a recep- tacle for all of the pus, mucus, and other inflamma- tory products which are thrown off, the retention of which retards the resumption of the normal functions of the eye. Immediately before the flushing a few^ drops of a four per cent solution of cocaine should be instilled into the eye — then the flushing has not the least dis- agreeable effect upon the patient. In iritis, from whatever cause, during the active stage, the eye should be covered with heated pledgets of dry cotton or wool, as light as possible, so that the eje may be kept warm with the least pressure pos- sible. Cysts of the Iius. Cysts of the iris are very rare, and are usually the result of an injury. They usually appear as transjjarent vesicles on the surface of the iris, either attached by a broad base or a pedicle, usually how- ever by the former. The treatment is to excise that portion of the iris to which they are attached. Congenital Malformations of the Iris. The following conditions may be regarded as the congenital malformations of the iris: aniridia, colo- boma, corectopia, heterochromia, persistent pupil- lary membrane, and polycorpia. Aniridia is that condition of the eye in which the CONG?:NITAL.:\IAT,l'r)RMATTC)NS OF THK IRIS. 171 iris is wanting;. This defect is rare. It is also known as iridcrciHia. Aniridia may atTeet both (\yes. When there is e-ntire absence of the iris, the ciliary processes can be readily seen. Those persons who are affected with absence of the iris snffer very mnch from the effects of the light, for the protection of which the Htoiopaic glasses shonld be prescribed. Colohoma is that condition of the iris in which there is a cleft or fissure, resembling an artificial pupil. This fissure of the iris is usually directed down- ward, and is more frequent in both eyes, than in a single eye. This cleft is sometimes continued into the ciliary body and choroid. Corectopia is an eccentric position of the pupil. The normal pupil is a little below the center of the iris, and to the nasal side, but is not readily observed. In corectopia the eccentric position is very easily seen. Heterochrwnia is that condition in which there is a difference in the color in one iris, or that condi- tion in which the color of one iris differs from that of the other. This condition is due to a want of uniform pig- mentation, and is not significant of any pathological state. Called also, heterophthalmiis. Persistent pupillary memhrane is that congen- ital condition of the iris in which the fibres are seen to arise from the anterior surface of the iris and pass across the pupil to the opposite side. 172 TKXT-BOOK OF OPHTHALMOLOGY. These fibres have the appearance of threads, and are either single, or often composed of many, usually in a group. When the pupil is contracl>ed the fibres relax and float about in the aqueous humor; when, how- ever, the pupil is dilated, the fibres are straightened ^nd tightly drawn across the pupil. Persisting Pupillary membrane. 1. Pupil contracted. 2. Pupil dilated. ( Wickerkiewicz. ) Figure 23. This defect is not easily detected, and as it does not usually interfere very much with the vision, the risk of an operation in removing it, is not justifiable. I have known these fibres, in one instance, to become detached, by the stretching of them, in wide dilata- tion of the pupil. Persistent pupillary membrane is probably the result of an incomplete resolution of the embryo- logical membrane, which closes the pu]3il in utero. Pohjcorpia signifies more than one pupil, or a number of pupils in the same eye. Where there are many pupils, it is usually IRIDECTOMY. 17.^ caused by the remaining fibres of persistent pupil- lary membrane, crossing in different directions. Iridectomy. This operation consists in the excision of a part of the iris, and is indicated in many affections and conditions of the eye, as in glaucoma, chronic iritis, exclusion and occlusion of the pupil, in some forms of cataract as the pyramidal, and in central opacity of the cornea. The instruments necessary for the performance of an iridectomy are a speculum, fixation forceps, a Graefe's cataract knife, a pair of iris forceps, which may be either curved or straight, and a small pair of scissors curved on the flat. It is not necessary to use an anaesthetic, except for children or when the eye is very sensitive from injury or a long continued inflammatory condition. If we do not give an anaesthetic, then the eye must be well cocainized. A four per cent solution of cocaine dropped into the eye every two minutes for a quarter of an hour, will so thoroughly anaes- thetize it, as to render it entirely insensible to the procedure necessary in this operation. I use the Graefe cataract knife to make the cor- neal incision, instead of the lance-shaped knife gen- eralh' recommended in this operation. The incison is made in the sclero-corneal tissue, about one line posterior to the edge of the clear portion of the cornea. This incison should be made in the same manner as that for tlie extraction of 174 TEXT -BOOK OF OPHTHALMOLOGY. cataract, but it should be smaller. When the in- cision is completed, it is usual for the iris to pro- lapse, especially if it is not adherent, when it can be grasped with the iris forceps and gently pulled out and cut off with the scissors as close as possible to the ciliary insertion. This is very important, especially in glaucoma, in which case the best re- sult is secured by a large iridectomy well into the ciliary body. We should be very careful that the v/ound is left clear; that is, that no portion of the iris is left within its lips, and that it is perfecly cleared of all extraneous body. There is nothing that will con- tribute more to a long continued irritation of the eye following an iridectomy than the intrusion of a portion of the iris. If the iris does not prolapse immediately after the incision is made, then we must introduce the forceps or the iris hook and draw it out; but great caution must be observed in this procedure not to wound the crystalline lens, as its opacity w^ould be sure to follow. If the iris is not adherent, the operation is very simple, and is usually easily performed, but if there is an adhesion of the iris to the lens capsule, or if plastic lymph has been thrown out and organized by the formation of a membrane in the pupillary space, then the operation is very difficult, especially when it is made for the purpose of securing an arti- ficial pupil. A light compress bandage should be placed on the eye and quiet maintained for several days. IRIDOTOMY. 175 IllTDOTOMV. Iridotoiiiv consists in makini;- an incision into the iris where the pnpil has been ch)se(l by inflam- matory^ deposit, with the expectation that the edges Avill retract snfficienly to make an opening large enough to serve as a pupil. Various instruments have been devised for this purpose, such as the sickle-pointed knife, and the scissors of M. de Wecker. 176 TEXT -BOOK OF OPHTHALMOLOGY. CHAPTER IX. DISEASES OF THE CHOROID. Choroiditis. €HOROIDITIS, an inflammation of the choroid. In all cases of choroiditis there is an ex- udation of some character, into the sub- stance of the choroid, hence the term exudative choroiditis. The exudate may be sa^iis, plastic or purulent. The serous and plastic varieties belong to what is known as the non-suppur^ative form, and the puru- lent to the suppuratire form, therefore, non-suppu- rative and suppurative choroiditis. The nonsuppurative form may undergo re- sorption, but the choroid is always more or less im- paired at the point of the exudate. After the resorption of the exudate there always remains, at its situation, a denuded, an atrophied or a pigmented spot. The above conditions are brought about in this manner: The exudate having become resorbed, absorption, retraction or cicitrization of the involved tissues takes place, leaving the sclerotic exposed, or the choroid atrophied, or newly-formed connective tissue at the seat of the exudation. Should the retina become involved with the ex- udation, as it often does, it also undergoes the same DISKAvSES OF THE CHOROID. 177 chcan^es in its structure as with the choroid, that is, it may become entirely absorbed or atrophied, or newly-formed connective tissue deposited at the seat of the exudate. If the inflammation remains confined to the choroid, then there is no outward indication of in- flammation observable. The only manner in which the disease manifests itself is observable to the patient, in the defect of his vision, or through the ophthalmoscope to the physician. Choroiditis is very chronic, owing to the time it takes an exudate to resorb, together with the process preceding the full completion of atrophy and cicitri- zation of that part of the choroidal tissue in w^hich the exudation occurred. The tendency of choroiditis is to recur, and it is not infrequent for cases to terminate in partial, if not total loss of vision. Choroiditis may, by continuity of structure, pass over to the ciliary body and the iris. ' The causes of choroiditis are syphilis, scrofula, rheumatism and meningeal and cerebral lesions. It is sometimes congenital, and is almost always pres- ent in very high degrees of myopia. For convenience of study the symptoms of non- suppurative choroiditis may be divided into the sub- ject ur and the objective. The subjective symptoms of non-suppurative choroiditis are: 1. Dimness of vision. 2. Distortion of images (metamorphosia). 178 TEXT -BOOK OF OPHTHAIvMOLOGY. 3. Sensations of sparks, bright spots, balls of fire, sparkles of light, etc. (photopsia). 4. Black spots floating in the field of vision (scotoma). The objective symptoms are: 1. YelloAvish spots, indistinctly outlined. (Ob- served only during the continuance of the exudate, and before complete resorption). 2. Light colored spots. (Observed during the process of resorption, at about the time it is com- pleted.) 3. White spots. (Complete atrophy of pigment and resorption of exudate.) 4. White spots, either dotted or lined with pig- ment. (Incomplete atrophy of pigment.) 5. Floating bodies of black flakes in the vitre- ous, (observable only in the advanced stage of choroiditis). , Contrary to almost all other affections of the eye involving the permanent loss of vision, it is not usual for the patient to suffer pain in the non-sux)- purative form of choroiditis; indeed it often occurs that the patient loses an eye from this affection without being aware that it has been in any manner diseased, until he accidentally discovers that his vision in that organ is materially impaired or en- tirely lost. Such a condition, however, is liable to occur only when the disease affects but one organ, but as choroiditis generally affects both eyes sooner or later it is not usual for it to affect an eye for any consider- able length of time before it is discovered. DISEASES OI- THE CHOROID. 179 Vision in choroiditis being more or less dis- turbed, the patient consults his physician, not be- cause he is suffering;' pain, but because of the gradu- ally increasing dimness of sight, which is more or less annoying, owing to the extent of the exudation and the portion of the fundus covered by it. Should the exudate be deposited in the region of the macula lutea it is known as chorioiditis cen- tralis, and the vision is usually disturbed by it to a very sreat extent. If the exudation is distributed generally over the fundus, it is termed choroiditis disseminata, with more or less loss of vision, although not so much as in choroiditis centralis; however, in choroiditis disseminata it frequently occurs that the region of the macula lutea is not disturbed to a very great extent, and central vision may be fairly clear, while that of the other portions of the retina is consider- ably deranged. Besides the dimness of vision, there is a sensa- tion of glimmering. This condition is almost con- stant in the incipiency of exudative choroiditis, and is caused by the imperfect manner in which the retina at the point of exudation receives impressions of images. Metamorphosia, or the distortion of images, is a frequent condition in exudative choroiditis and is caused by the retina being raised at the point of ex- udation, the regular contour of the fundus being thus interfered with by the exudate in the choroid. Photopsia, or the sensation of sparkles of light and balls of fire before the eye, is a very evident 180 TEXT -BOOK OF OPHTHALMOLOGY. symptom of irritation of the retina. This sensation is present as well when the lids are closed as when the eyes are open, and continues a variable length of time, but is more marked during the incipiency and during the inflammatory condition of the cho- roid which extends over a period often of several months. It is impossible for the choroid to be affected to any great extent without injury to the retina, and especially is this the case when there is an exten- sive exudation into the choroid, because the sur- rounding portion of the retina also becomes infil- trated with this' exudation, in which manner cho- roido-retinitis is established. As exudative choroiditis often complicates the retina, it frequently happens that defective vision in some portion of the retina occurs as a result of the choroiditis. This condition is known as scotoma^ and signifies that a certain portion of the retina is insensible to light, which is indicated by the pres- ence, to the patient, of a black speck before the eye. The characteristic peculiarity of a scotoma is its moving with the eye, and not fioating before it, as in muscae volitautes; and this distinction must be particularly observed, for often very much depends upon our diagnosis before making an ophthalmo- scopic examination, as the defect in the retina, which causes the scotoma, may be so obscure as not to be detected, even with the ophthalmoscope. In scotoma the dark spots observable to the pa- tient, although they may vary much in form and figure, are constant and have well defined shapes, DISEASES OF THE CHOROID. 181 ^nd if there are more than oue, tliey preserve a fixed relation to each other, while in muscae volitantes the figures vary in shape, are not constant, and if there are several, have no fixed relation to each other, but float about promiscuously among them- selves. As the muscae volitantes following choroiditis is a symptom which is due to floating opacities in the humors of the eje, especially in the vitreous humor, it is easily detected with the ophthalmo- scope. This condition is occasionally the result of a hemorrhage which frequently accompanies the choroiditis. It should be understood that a scotoma is not always the result of a choroiditis, for a portion of the retina may be imperfect or wanting, congenit- ally, or it may be the result of a rent in the retina, caused from a blow, or from a hemorrhage or an in- flammation of the retina. The objective symptoms, in exudative choroid- itis are demonstrable with the ophthalmoscope only, the most important of which, in the early stage of the exudative process, are the yellowish spots at the point of the exudate. There is always one peculiarity with regard to these spots, and that is, the outlines are decidedly indistinct; in fact the normal tissue is so blended with that which contains the exudate, that it is im- possible to appreciate the point of transition. After resorption of the exudate begins and there is beginning atrophy of the choroidal tissue, the out- lines of the spots are somewhat better defined, and 182 TEXT -BOOK OF OPHTHALMOLOGY. the spots themselves become whiter, are, in fact, a yellowish white, and their edges, although irregular in outline, are easil^^ recognized. As the resorption o'f the exudate continues, atrophy of the choroidal tissue is inaugurated, and continues until the spots are changed to almost a pearly white. In some cases atrophy of the choroidal tissue is never completed, and there will always remain depo- sitions of unabsorbed pigmentary tissue, generally around the edges of the spots, although occasion- ally in or near their centers. If the choroiditis is uncomplicated, the retinal vessels are seen passing over the atrophied spofc. If they do not pass over, but run only to the margin of the patch, then the retina has become involved also. Sometimes, in the very early stages of choroid- itis, the vitreous seems to be full of dust like float- ing opacities; these are due to the exudation of in- flammatory material, and are readily seen with the ophthalmoscope, and move among themselves when the eye is moved. The choroid and the iris being so closely con- nected, forming as they do, with the ciliary body, one continuous whole, the causes of the different forms of choroiditis may be regarded with consider- able reasonableness, in the same light as those of the different forms of iritis. Like iritis, exudative choroiditis is usually as- sociated with some depraved state of the constitu- tion, as syphilis, rheumatism and gout; but by far the DISEASES OF THE CHOROID. 183 most freqiieut cause is syphilis. It lias always ap- peared to me a most fortunate thing that the fijreat majority of the cases of choroiditis is of syphilitic origin, for syphilitic choroiditis is most amenable to triuitment, and a rapid improvement is usually ob- tained in a remarkably short time, with the proper remedies. Treat iiicnt. — The first and most important mat- ter in the treatment of exudative choroiditis of the non-suppurative form, is rest for the eyes and their protection from the bright light. The first can be accomplished b}^ wearing smoked or colored glasses, and the avoidance of the light by remaining in doors as much as possible. In regard to rest for the eyes, they should not be strained by any work requiring their use. This is very important, and should be strictly enforced, by paralyzing the accommodation if necessary. The symptoms in the incipiency of choroiditis and «laucoma are so nearly analogous, that it is necessary to differentiate them before a mydriatic is applied to the eyes, if we do not desire to suffer the reproach of having precipitated an attack of glaucoma. If w^e have demonstrated, with the ophthalmo- scope, that an exudation has taken place, then we are safe in using the mydriatic. If not, then we would better depend upon the honesty of the patient in observing our instructions. As soon as it is possible to make an examina- tion of the eye with regard to its refraction, it should be done, for I am inclined to think that many of these 184 TEXT -BOOK OF OPHTHALMOLOGY. cases of choroiditis, that make their appearance in persons of about fortj^-flve years of age, are due to the strain consequent in the beginning of presby- opia. In refractive error, all the strain, if any, is upon the ciliary body; and as the ciliary body is so closely connected with the choroid, any strain upon it will certainly compromise the choroid, and more espe- cially if there is a latent tendency to a choroiditis. All defects in the refraction should be fully cor- rected, and examinations made from time to time in order that a change in the glasses may be made when neccessary. The general health is a matter of great import- ance, especially in elderly people, and remedies suit- able to each particular case must be prescribed. The bowels must be w^ell regulated, and in cases of anaemia, suitable tonics must be given. Should we have cause to suspect syphilis, the iodide of potassium or mercury should be adminis- tered. I am very much in favor of the iodide of po- tassium in large doses, in the young as well as in the feeble and the aged. I usually prescribe for the adult one-half teaspoonful (30 grs.) of the saturated solution, in two or three tablespoonsful of milk, be- fore meals. In children from two to ten years of age, I prescribe from fifteen to twenty drops of the same. The iodide of potassium should always be given in the saturated form, and should be taken in milk. I have never known the iodide of potassium given in this manner, to disagree with the most irritable DISEASES OF THE CHOROID. . 185 stomacli; in fact I have known of many irritable and weak stoniaehs to have been cured by the use of this remedy in the manner prescribed. Inunctions of mercurial ointment should be practised, especially if the patient is robust and youno'. The feeble and the aged cannot withstand its depressing effects, and it should not be resorted to in those cases. Pilocarpine, for the purpose of producing dia- phoresis in cases where there is much opacity of the vitreous, has been recommended, but it must be ad- ministered with very great care. For the aged there is no tonic that equals strychnia. ■Suppurative choroiditis. The suppurative form of choroiditis is characterized by an exudation of pus in the choroidal tissue, or between the choroid and retina, which rapidly extends, on account of contijiuity of structure, to the ciliary body and iris, as well as to the vitreous humor. Unlike the non-suppurative form, the patient, in suppurative choroiditis, suffers severe pain. There is extreme tension, the iris is pushed forward, and the anterior chamber is very shallow. If the eye is examined in the incipiency of the affection, before the humors become clouded, the ophthalmoscope will reveal the purulent mass pushed forward into the vitreous, giving a yellow reflection. The vision is gradually lost, the lids become oedematous, there is chemosis of the conjunctiva, the cornea becomes opaque, and pus is deposited into the anterior chamber, forming an hypopyon. 186 TEXT -BOOK OF OPHTHALMOLOGY. Because of the involvement of all the tissues of the eye and its appendages, in the inflammatory action, the globe is pressed with such great force against the swollen lids, that neither the eye nor the lids can be moved. Suppurative choroiditis is usually caused from wounds of the eye, either from accident or by an operation, especially that for the extraction of cat- aract. How^ever, since antiseptics have been re- sorted to, and aseptic precautions have been so strictly observed in all operations upon the eye, sup- purative choroiditis, from operations, has greatly diminished. In some rare cases suppurative choroiditis is caused by an extension of inflammation from the cornea and the iris, as in sloughing ulcers of the cornea. It also occurs in different forms of septi- caemia, and in children in cerebrospinal meningitis. Treatment in suppurative choroiditis avails lit- tle, except, perhaps, in that following cerebro-spinal meningitis, from which a few cases of recovery are upon record; and in these cases it is really a ques- tion as to whether the exudate w^as not plastic, in- stead of purulent. Fomentations as hot as can be borne, should be applied frequently, and a free incision into the scle- rotic, so as to give passage to the pent up contents, should be resorted to, at the earliest possible mo- ment, in order to relieve an extended course of suffering. DISEASES OF THE CHOROID. Ig7 The subsequent* treatment consists in dressing the eye aseptically. The inflaniniatiou now grad- ually subsides, leaving the eye in that condition known as phthisis bulhi. 188 TEXT- BOOK OF OPHTHALMOLOGY. CHAPTER X. DISEASES OF THE CILIARY BODY. Cyclitis. CHE ciliary body being so closely connected with the iris and the choroid, can scarcely avoid be- ing more or less implicated, should either one or both of the latter suffer inflammatory action; neither can there be an inflammation of the ciliary body without the choroid and iris being more or less affected; therefore, inflammation of the ciliary body is seldom found to occur without a similar condition of either the iris or choroid, or both, except in case of direct injury to that structure. In cyclitis, there is always tenderness over the "danger zone" and injection of the blood-vessels in this region. The aqueous humor is cloudy, and flocculi of lymph, or pus, and sometimes blood are seen in the anterior chamber. The vision is always more or less impaired owing to the extent of the turbidity, not only in the aque- ous humor, but in the vitreous also. The vitreous humor as seen with the aid of the ophthalmoscope^ is more or less filled with floating opacities. Cyclitis is a dangerous affection and may result in a destructive suppuration and atrophy of the globe, under the best advised treatment. DISEASES OF THE CILIARY BODY. 189 There is another danger besides suppuration, and equally fatal to th(^ integrity of the eye, and that is a thinning of the walls of the sclerotic over the ciliary body, consequent to the long continued in- tlammatory action, and the formation of a ciliary staphyloma. In case this occurs, the removal of the eye in order to prevent sympathetic inflammation of its fellow, is imperative. Cyclitis occurring with, or as the result of choroid- itis or iritis, demands the same treatment as those affections, and like them, may entirely recover. 190 TEXT -BOOK OF OPHTHALMOLOGY. CHAPTER XI^ SECTION I. DISEASES OF THE RETINA. Retinitis. RETINITIS, an inflammation of the retina. Retinitis may be primary or secondary. In primary retinitis the affection begins in the retina. In secondary retinitis the retina is implicated through an inflammatory process which begins in some other part of the eye. Primary and secondary, as here used, should not be confounded with the terms idiopliatie and symp- tomatic, for the retina may become affected primar- ily, that is, before other parts of the eye are affected, and the affection would not be idiopathic, but may proceed from some prior disorder of the system at large. Idiopathic rentinitis, that is a retinitis not pre- ceded or occasioned by some other disease, is very rare, and seldom occurs. It is usually caused from exposure of the eye to a very bright light, or from severe and long continued strain upon the eye in observing a near point. Symptomatic reti)iitis, or that which is the re- sult of some constitutional disorder is usual, the most common of which are the following: DISEASES OF THE RETINA. 191 Albuminuric* retinitis. Syphilitic retinitis. Glyeosuric retinitis. Leukemic retinitis. Another form which is very common, pigmen- tary retinitis, or retinitis pigmentosa, has been at- tributed to constitutional affections, chiefly to inher- ited syphilis, but this view is not i^enerally accepted. Albuminuric retinitis is a form of retinitis which is due to albuminuria, and is the most common form of retinitis. It frequently occurs that the first symptom of albuminuria is found in the appearances of the retina as is often revealed by the ophthalmoscope, in search of a cause for the attending defective vision. Albuminuric retinitis is due to morbid changes in the connective tissue fibres of the retina, occas- ioned by a toxic effect, from changes in the blood. Loss of transparency of the retina is one of the first ophthalmoscopic impressions observed, and is manifest in pathological changes, just as a loss of transparency in the other transparent tissues, as the cornea, the aqueous, the lens, and the vitreous; consequently, minute alterations in the retina are discovered very early in albuminuria, if a careful examination is made with the ophthalmoscope. The connection between kidney lesion and reti- nitis is very obscure, but there is doubtless a devel- opment of disease, or a morbid change affected in the walls of the retinal vessels in consequence of an altered composition of the blood, which change results in inflammation itself. 192 TEXT -BOOK OF OPHTHALMOLOGY. Albuminuric retinitis is of serious import, and patients suffering from it do not survive long. Fuchs claims that within his experience they usually suc- cumb within a year. The primary effect of albuminuria upon the retina is inflammatory, after which there is a retinal degeneration, especially if the albuminuria continues for any great length of time. There is a form of albuminuric retinitis that is very transient, which has been denominated alhii- minuric amaurosis, and which is observed in preg- nancy and other conditions producing acute nephri- tis. It is really a question whether the albumen in the blood causes a transient congestion of the retinal vessels, or if blindness is not due to its toxic effect upon the nerve filaments. In albuminuric retinitis both eyes are affected, but almost always one to a greater extent than the other. The first subjective symptom of albuminuria is^ frequently the defective vision, and for this reason, a very careful ophthalmoscopic examination should be made in all cases of decreasing vision which are obscure, and cannot be attributed to a refractive error, or other obvious cause. Treat nioit. — The local treatment in albuminuric retinitis is simply rest for the eyes, and the use of smoked glasses to protect them from the bright light. The general treatment should be directed to the kidneys. Syphilitic ^rtinitis is the next most common form of retinitis, if it is not the first. DISEASES OF THE RETINA. 193 Syphilitic retinitis is i^enerally associated with clioroiditis, liciice clKtroido-rctiiiifis, and it-; sidxji'di- nate to it, having originated in the choroid; liowever primary syphilitic retinitis is occasionally met. Syphilitic retinitis occnrs in both the congenital and acquired forms of syphilis. It may affect one eye alone, but it generally affects the second eye sooner or later, and may occur several months or as much as a year afterward. In cases of inherited syphilis, the affection most often occurs between three years and fifteen years of age, although it has been seen as early as six months. In acquired syphilis the retinitis usually ap- pears in from six months to two years after infection. Defective vision is usually ver^^ marked from the very incipienc}' of the affection, and if treatment is neglected, often continues until there is total blind- ness. The tendency of syphilitic retinitis is to sudden relapses and aggravation of the affection after tem- porary amelioration or improvement. Because of this inclination to recur, syphilitic retinitis usually continues in its course from bad to worse, until use- ful vision is entirely lost. Trcatiiirnt. — The treatment in syphilitic retinitis is local and general. As in retinitis from any cause, very little can be accomplished by local means except to cover the eves with smoked glasses in order to protect them from the bright light. Excessive strain in at- tempting to read or to do fine work with the eyes, or 194 TEXT -BOOK OF OPHTHALMOLOGY. in fact any near work should be avoided, and tlie eyes given complete rest. If seen early, syphilitic retinitis, like syphilitic choroiditis, is very much benefited by an alterative treatment, but it must be energetic, and because of the tendency to relapses and exacerbations it must be continued as long as possible. I am sure that many of these cases can be held in suspension or temporary extinction, but the spark is there, and can be fanned into a flame on the least provocation, such as a neglect of the treatment, the abuse of alcoholic drinks, or overheating from any cause. The administration of the iodide of potassium internally, and inunctions of mercurial ointment, as recommended in choroiditis, should be resorted to. The iodide of potassium must be continued as long as it agrees with the stomach, and the inunc- tions until there is evidence of ptyalism, when their' use should be discontinued until the effects pass off, when they can again be renewed. Ghicosuric retinitis, or diahetic retinitis^ is due to the toxic effects of glycosuria upon the retina. It is a very rare affection, occurring principally in old people. The ophthalmoscopic appearances of glycosuric retinitis are so similar to those of the albuminuric form that it is impossible to distinguish them by this means alone, and recourse must be had to urinalysis. Treatment. — As the retinitis is due to the general health, treatment must be directed to the diabetes. The only local means emplo3^ed are those which are indicated in the other forms of retinitis; the eyes DISK ASKS OI' TIIK RETINA. 195 must be protect(Ml from bright li<;lit by smoked glasses, and all strain must be avoided. IjCuJx-ciitic retinitis is due to an altered state of the blood, marked by an excessive and permanent increase in the white corpuscles of the blood. ^^ision ma}^ or may not be affected to a very great extent. The tendency in this form of retinitis is to hemorrhages, which may cause complete blind- ness. Leukemic retinitis is very rare, as in only about one-fourth of the cases of leucocythemia is the retina in the least affected. Treatment. — The treatment must be directed to the o:eneral health, with the same observance in pro- tecting the eyes from bright light and strain, as in other forms of retinitis. Pigmentary retinitis, or retinitis pigmentosa, is an affection of early life, progressive but chronic, often requiring many years to complete its course. The inflammation attending this affection is not very marked, in fact it has been asserted by some authors to be non-inflammatory in its character, the retinal lesion being the result of an atrophy or pig mentary degeneration. The most prominent symptom in pigmentary retinitis is that condition known as hemeralopia, or night blindness, in which the patient sees much worse at night, or in a dim light, than his vision when in bright sunlight would seem to justify. Pigmentary retinitis attacks both eyes simul- taneously, is most frequently observed in males, and as before mentioned is essentially a disease of 196 TEXT- BOOK OF OPHTHALMOLOGY. childhood, but occasionally it presents itself at from twelve to fifteen years of age. The causes of retinitis pigmentosa are obscure, and as it often affects several members of the same family, heredity- is regarded as an influential agent. It has frequently been found in families where there were prevalent defects in intellect, or several mem- bers were deaf and mute. Treatment. — Treatment is of doubtful benefit. Electricity and hypodermic injections of strychnia have been resorted to by some, who have claimed a temporary improvement in vision, but this may be ascribed probably to the inspiring hopes of the pa- tient in anticipation of a favorable result. If there is a history of syphilis, the alterative treatment indicated in the other forms of retinitis should be resorted to. So many varieties of retinitis have been recog- nized by authors that they are perplexing to the stu- dent, and serve to confound rather than make plain a subject which can be simplified to such a degree as to be considered under the five common and gen- erally recognized forms already given, and which embrace fully 95 per cent of all cases of inflamma- tion of the retina. Beside the varieties already mentioned, there are the pur}ilent, hemorrhaf/ie, apopleetie, ventmli^, proUferans, etc., the consideration of which is not justified, inasmuch as they are rather conditions of common forms of retinitis than distinct affections. For instance, a hemorrhage is liable to occur in any DISEASES OF THE RETINA. 197 of tlio coiiiinon forms of retinitis; l)ut for this reason aloncs it sliould not be classified as a special variety. The sani(^ may be said of the purnlent, which is rather the course or the r(»snlt of oiw of the common forms of retinitis; the centralis, which indicates the point of attack; and the proliferans, to the peculiar- ity of the stria formed from the connective tissue in the retina, as a result of an inflammatory action. Another justification for simplifying the vari- eties of retinitis, is that the treatment in all forms is so general. It resolves itself into a very small com- pass: rest to the eyes, protection from bright light, attention to general health. Ophthalmoscopic appearances as observed in the different varieties and conditions of retinitis, in the order of their usual occurrence: Albuminuric Retinitis. 1. Hyperaemia of the pax^iHa and of that por- tion of the retina immediately surrounding it, as is evidenced b}^ a dull haze over this portion of the fundus. 2. Hemorrhages on and in the region of the disk. 3. After the disease is well established, small white spots, collected in groups around the yellow spot. Syphilitic Retinitis. 1. Slight hyperaemia of the papilla, and a con- siderable portion of the fundus, but most marked 198 TEXT- BOOK OF OPHTHALMOLOGY. about the region of the yellow spot, and around the edge of the disk. 2. Hemorrhages occasionally, but rarely occur. 3. ''Dust like" opacities in the vitreous. These opacities are generally diffused, often filling the en- tire humor, but there are present sometimes, large flake-like or membranous opacities. Opacities in the vitreous are pathognomon of syphilis. 4. Small white dots occasionally occur about the macula lutea, but generally very late in the affection. Glycosueic Retinitis. 1. Papilla very pale with margins indistinct, with slight opacity of the fundus of the retina, and along the course of the retinal vessels. 2. Small retinal hemorrhages about the j^ellow spot, usually star-like in appearance. 3. Opacities in the vitreous, usually of hemor- rhagic origin. Leukemic Retinitis. 1. Yellowish, rounded, hemorrhagic spots in the region of the yellow spot, and at the periphery of the fundus. 2. Small white spots and white streaks along the course of the retinal vessels, due to accumula- tions of leucocytes, which have passed bodily through the vessel walls. 3. Fundus paler than normal, owing to the altered condition of the blood. detachment of the retina. 199 Pigmentary Keti niti s. 1. Star-like iMti^rcoinimiiiicating spots of pijj;- mentatiou, first in tlu^ periphery, but gradually ad- yancing in the protracted course of the disease, mostly along the course of the yessels, toward the yellow spot. 2. The papilla of grayish, yellowish, waxy ap- pearance. 3. The arteries and veins both yery small and threadlike in appearance. 4. Opacities in the yitreous, and posterior polar cataract often present in the later stages. SECTION II. Detachment of the Retina. The retina may become detached from the chor- oid, either from the effects of an injury upon the eye, as a blow, or from the effects of disease of that organ. The diseases which are liable to effect detach- ment of the retina, are retinitis, especially the albu- minuric form, choroiditis, diseases of the yitreous, particularly those which result in an atroiDhy or wasting away of the yitreous, and intraocular tumors, principally sarcoma of the choroid. A sudden loss of the yitreous, either as a result of an injury or an operation upon the eye, often causes a detachment of the retina; and it has been 200 TEXT -BOOK OF OPHTHALMOLOGY. known to occur from the sudden loss of the aqueous humor, as in cataract operation. Detachment of the retina may be complefr or partial. In complete detachment of the retina, the whole of the retina is dragged away from the choroid, ex- cept that portion around the optic disk. In partial detachment, only a part of the retina is separated from the choroid, which may vary in ex- tent from a very small portion to that covering a very large area. In case the detachment follows a blow or an in- jury of the eye, the intervening space is usually filled with blood, or a bloody fluid; when it follows disease the subretinal fluid is usually clear. The amount of disturbance of vision depends upon the part of the retina which has become de- tached, and the extent of the detachment. If the macula lutea, or its region is implicated, it obviously follows that the vision is very seriously affected, if not entirely lost. Distortion of images is also a prominent symp- tom in detached retina, owing to the unevenness of the retina at the point of separation. Detachment of the retina is usually seen at the lower portion of the fundus. If the exudate should take place in some other portion of the retina, the tendency is for the fluid to work its way by force of gravitation, between the choroid and retina, to the lower portion of the fundus. Whatever portion of the retina is detached, the field of vision will be affected upon an opposite part; DETACHMENT OF THE RETINA. 201 for instance, the detachment is on the lowi^v i)()ition of the fundns, the defect in vision will occur in the upper portion of the visual field. Should the de- tachment occur on the nasal side of the fundus, then the si<>ht suffers on the temporal side of the field of vision. No matter what part of the fundus is af- fected, except its central portion, the defect in vision is always found on an opposite place in the field of vision. There is usually great diminution of tension in retinal detachment. This is caused by a shrinkage of the vitreous. Treatment. — Rest in the recumbent posture, and firm presssure upon the eye, with cotton pads, sup- ported by a bandage. The iodide of potassium should be given in large doses, in the manner already heretofore described, for its absorbent effect. The bowels must be reg- ulated. Diaphoresis has been recommended by the use of pilocarpine, but if it is administered, it must be done with great caution. Ophthalnioscoplc appearances in detached retina: The detached portion of the retina has the ap- pearance of a grayish membrane, projecting forward into the vitreous. The blood vessels can be as readily seen upon the detached portion as upon the healthy, but they do not appear continuous, because at the limit of the healthy retina they bend over and are entirely ob- scured, when they are again seen upon the detached 202 TEXT -BOOK OF OPHTHALMOLOGY. portion, because at the limit of the health}^ retina they bend over on account of the protuberance of the detached portion, caused by the exudate beneath it.. DISEASES OF THE OPTIC NERVE. 203 CHAPTER Xn. DISEASES OF THE OPTIC NERVE. Optic Neuritis. TT|S the name indicates, optic neuritis signifies W^ an iiiftamnidtion of the optic nerve. J I The terms ''papiUitls,'^ "descending neu- ritis;' and "choked disc;' ophthalmically imply the same condition, but as our observation is confined to the optic disc or papilla alone, the term "papilli- tis'' has hitherto been applied ; but as the optic nerve cannot usually be affected at the papilla alone, and as papillitis is simply an evidence of the general con- dition of the nerve, optic neuritis is considered more preferable. As in inflammation of other parts, the papilla is swollen, in some instances to such an extent as to bulge forward into the vitreous, giving it, as de- scribed by some authors, a mushroom appearance. This condition originally suggested the term "choked disc.'' In inflammation of the optic nerve, the well marked marginal lines of the disc, as seen normally, have entirely disappeared, and in its stead is the "woolly" or hazy appearance. The central vein is increased in size, and its 204 TEXT -BOOK OF OPHTHALMOLOGY. branches are distended and tortuous, while the ar- tery is contracted. In the early stages of inflammatory action the color of the disc is red or livid, owing to the intensity of the congestion; afterward it is changed to a gray- ish, or grayish-white appearance, in the form of stria extending from the papilla into the surrounding retina. On account of the extreme congestion of the veins, there are occasionally hemorrhages, marked by flame-shaped or diffused patches, on or near the papilla, although these hemorrhages do occur very frequently in other portions of the fundus. .^ Strange to say the vision is frequently very little impaired, during the inflammatory stage; however, It is occasionally very much diminished, even when the inflammatory action is not very well marked In due course of time, optic neuritis reaches its height, after which there is a gradual abatement of all inflammatory action. The opacity slowly subsides, and if resolution takes place promptly, the papilla becomes perfectly = 18 inches. Concave glasses cause parallel rays of light in passing through them to become divergent (Fig. 33). The focus of a concave lens is found by contin- uing backwards its emergent rays to a point where they all meet (Fig. 34). Figure 33. Figure 34. With this knowledge of lenses, I think we can properly appreciate the subject of errors of refrac- tion. The errors of refraction consist mainly in the length of the eye. The eye is either too long, or too short. Now, there is within the normal eye the crystalline lens, and the ciliary muscle that controls the shape of the lens in such a manner that when we look at near objects (10 to 18 inches distance) the lens becomes more convex, and when we look at objects at infinite distance (20 feet or more) the lens returns to its usual shape, and it is less convex than when looking at a near point. This is the natural conditon of the lens in the normal eye, and w^e see without any effort, that is, without "strain.'^ This property of the eye in adapting itself to see at different dis- tances is known as accommodation. 266 TEXT -BOOK OF OPHTHALMOLOGY. It follows then, the nearer the object is to the normal e^^e, the greater the accommodation or "strain;" the farther the object is away from the eye, the less the effort to accommodate or "strain.'' Now, if rays of light coming from infinite dis- tance, in passing through the crystalline lens, should focus upon the retina so as to form there a distinct image, then the eye is considered normal in its re- fraction or emmetropic (Fig. 35). But, should these rays of light (parallel rays) focus in front of the retina, the eye then is too long and w^e would be compelled to use a concave lens Figure 35. Figure 36. in front of the eye, that is, a lens that would disperse the rays of light sufficiently to cause them to focus upon the retina, and thus correct the defect (Fig. 36). This condition of the eye is known as myopia or short-sightedness, for a reason which we will pres- ently explain. If, upon the other hand, these parallel rays of light should focus behind the retina, then the eye is too short, and we would be compelled to place a convex lens in front of the eye, so that the rays of ELEMENTARY OPTICS. 267 light may be converged sufficiently to allow them to be focused upon the retina (Fig. 37)., This condition of the eye is known as hyperopia. Now, if the crystalline lens of the normal eye w^ere fixed, and were not possessed of considerable elasticity, it would be impossible for it ^the normal eye) to see objects plainly at a near point; objects then would be seen distinctly at a far point only, and the nearer they would approach the eye the less distinct they would become. But the eye is happily supplied with the means to overcome this obstacle, for the lens is so controlled that it is made to be- come very convex when the object is brought to a near point, as has hitherto been explained (Fig. 38). Figure 37. Figure (The white lines represent the normal eye at rest, that is, receiving impressions from a distance, and the dotted lines from a near point.) Thus the lens, by becoming more convex than when receiving rays of light from a distance, is enabled to focus those from a near point upon the retina. 268 TEXT -BOOK OF OPHTHALMOLOGY. But the crystalline lens, at about the age of 45 years, commences to lose its elasticity, and continues to become less and less flexible as age advances, until 70 years is reached, at which time it is so hard that the accommodation is entirely lost, and no effort can exert any influence upon its shape. This condition of the eye is known as presbyopia or far-sightedness, because the person thus affected can usually see well at a distance, w^hile vision is very much interfered with for near work. This condition requires the addition of convex lenses for near vision, the strength of the lens being gradually increased as the years advance. The property of a convex lens of thus increasing the conjugate focus of the emergent rays as the ob- ject is placed nearer to it, plays an important part in the errors of refraction, at one instance to the disadvantage, as in hyperopia,and at another to the advantage, as for near vision in myopia. Let us examine into the mechanism of hi/pcro- « pia, or that condition in which the eye is represented as being too short. We have represented here i)arallel rays passing through the eye and coming to a point on the other side of the retina. How can these rays be m.ade to focus upon the retina? We must either accommo- date sufficiently td make the lens convex enough to cause the rays to meet at the proper point, or in the event the error is so great, or the ciliary muscle that ELEMENTARY OPTICS. 269 controls the lens is so weak that we cannot,— then we must use in addition a convex lens (Fig. 39). Figure 39. Figure 40. If we are compelled to accommodate in order to see at a distance (focus parallel rays), then it fol- lows that we will be compelled to accommodate much more in order to see near objects, for we have been taught that the nearer the object approaches a con- vex lens, the farther upon the other side will the rays focus (Fig. 40). It is not unusual for the patient, who frequently has a considerable degree of hyperopia, to be able to accommodate enough to cause the lens to become sufficiently convex, that the rays of light may focus upon the retina, for not only a distance, but for near vision; but when this "strain" is kept up for a con- siderable time, the eye becomes greatly fatigued and may suffer serious consequences. There is a condition of hyperopia which is fre- quently mistaken for myopia. It is this: the hyper- opic eye, as has just been explained, is compelled to accommodate excessively in order to do near work, and constant near work with such an eye causes the 270 TEXT -BOOK OF OPHTHALMOLOGY. ciliary muscles which control the lens to become so cramped, that the lens is almost constantly in a fixed condition, and that for near work; when the lens is thus rendered very convex, the patient is not in a condition to see at a distance, for the rays of light in this case focus before reaching the retina. (Fig. 41.) In this case, as in mj^opia, a concave glass will cause the rays of light from a distance to focus upon the retina. But this glass will not remedy the de- fect but for the instant, for the moment that there is the least relaxation in the spasm of the ciliary muscle, which is liable to occur at anj time, then the glasses do no good, but work a positive injury. This condition of the eye I have called factitious or forced myopia , and it is very common, especially in overworked school children, and others who are compelled to do excessive eye work. Figure 41. Figure 42. It now remains to explain how increasing the length of its conjugate focus will be advantageous for near vision in myopia. The eye being too long in myopia, the rays of ELEMENTARY OPTICS. 271 li<;lit from a distance in passing- through its lens become focussed before reaching the retina. But we have been taught the nearer the object approaches a convex lens, the farther upon its op- posite side will the rajs of light which pass through it become united, as is represented in Fig. 42. (The white line represents the myopic eye, viewing objects from a distance, and the dotted lines at near work). It is thus seen that in high degrees of myopia the patient is unable to see very near objects without an effort of accommodation; although, in fact, the least accommodative effort, in many cases, would cause a blurring of the vision. To summarize: It has been demonstrated that the normal eye in a state of rest is adjusted for par- allel rays of light, and that these rays focus upon the retina without accommodative effort; at a near point with accommodative effort. If the eye is too short, the effort of accommodation, for near work especially, becomes too fatiguing, and the muscle which controls the lens, like any other muscle of the body which is overworked, may become spasmodically cramped, thus inducing a latent optical defect; that is, there may be an error in the refractive apparatus of the eye, but it is so disguised by reason of the cramp, that it is impossible to detect it without a thorough ex- amination of the organ during complete relaxation of its accommodation under atropine or other my- driatic. Otherwise, it is impossible to detect this error. 272 TEXT -BOOK OF OPHTHALMOLOGY. If the eye is too long, no action of the ciliary muscle can make the lens concave or adjust it so that the rays of light passing through it will focus upon the retina. To correct this defect, as we have hitherto explained, requires a concave glass. The normal eye then receives impressions upon its retina from infinite distance, without strain or accommodative effort; from a near point with only ordinary strain or accommodative effort, or with such an amount of effort only as was designed in nature to accomplish this function. It follows, then, if the media are clear and the retina normal, and the ciliary muscle is not disabled, that images will be received upon the retina and their impression carried to the brain with as little effort and as unconsciously as that of breathing, or as the action of the heart in the healthy individual. There is another defect in the refractive condi- tion of the eye, which, beside the defect in vision, is the cause of much nervous disturbance. This de- fect is known as astigmatism. Astigmatism is caused by an irregularity in the curvature of the cornea, or crystalline lens. Astigmatism is that condition of the eye in which the refraction varies in the different meridians. In this oondition of the eye, the rays which enter it along one meridian are brought to a focus before those which enter it along another meridian, thus the curvatures of its different meridians are not equal. ELEMENTARY OPTICS 273 In astigmatism the meridiau of greatest curva- ture is usually at right angles to those of the least curvature. Astigmatism, then, may be defined as the ina- bility to observe lines of the same intensity in one direction, as well as those at right angles to them. When it is possible for the eye to observe the horizontal lines distinctly, and the vertical lines are blurred, but can be made distinct with a convex lens, then we have simple lujperopic astigmatism with the rule, for it is usual for a convex, instead of a con- cave glass to make the vertical plain. If, however, a concave glass is required to make the vertical lines distinct, then we have simple myopic astigmatism, or astigmatism against the rule. Astigmatism is always witli the ride when a convex glass corrects the vertical line, and a con- cave corrects the horizontal. It is always against the rule, when a concave will correct the vertical line, and a convex the horizontal. In eompound astigmatism the eye is hyperopie or myopic in all meridians, but more so in some than in others. Mired astigmatism is that condition in which the eye is hyperopie in some meridian and myopic in others. So far, our discourse has been directed to monoc- ular vision, or to that of one eye alone. We must also take into consideration that in order to have perfect binocular vision, both organs 274 TEXT- BOOK OF OPHTHALMOLOGY. must be alike; that is, they must have the same re- fractive powers; but if on account of one or more of the muscles in one or both eyes becoming de- ranji^ed, so that it causes one of the eyes to turn in, or out, or up, or down, or in any manner away from its normal visional line, the images then will not properly merge, but will be more or less confused, and the continual effort or strain required to accom- plish the merging of the images is the fruitful source of the headaches of which we hear so much, and which are in no wise exaggerated. Dr. Stevens of New^ York City, to whom should be accorded the credit of making a practical classi- fication of the different forms of muscular defects of the eye, gives the following: Orthophoria denotes parallelism of the visual lines, or normal power of the muscles. Hctcrophoria, non-parallelism of visual lines. Esophoria, sl convergence of the visual lines, or insufficiency of the abductors. Exophoria indicates divergence of the visual line or insufficiency of the adductors. Hyperphoria indicates the visual line of one eye above its fellow. Cataphoria below its fellow. Hyper esophoria signifies a tending upward and inward. Hyper exophoria a tending upward and outward. INSUFFICIENCIES OF THE OCULAR MUSCLES. 275 SECTION II. The Causes and Effects of Insufficiencies OF the Ocular Muscles. The normal functions of the orbital muscles, when the eye is considered as a monocular organ only, are complicated; when we study their actions in connection with binocular vision, their offices ap- pear confused in the extreme; but when, in addition, there exists an abnormal condition in the action of one or more of these muscles, then we have a per- plexing skein to untangle. Such has the subject of insufficiencies of the orbital muscles proven itself to be. In seeking a remedy for an affection, we do so more intelligently by first searching for the under- lying' condition of which the symptoms are but the declaration. Hence in asthenopia of the orbital muscles, as in all other affections, we would, as far as possible,trace all symptoms back along the line of causation to their ultimate origin. We are thus necessitated to consider some of the most noticeable and common affections of the ocular muscles, whose •conditions are attributed to refractive abnormalities. For the purpose of being clearly comprehensi- ble, the subject will be discussed in the following order: 1. Does an error of refraction contribute in any manner to muscular asthenopia? 276 TEXT -BOOK OF OPHTHALMOLOGY. 2. What is the modus operandi of the impair- ment of the function of the ocular muscles in ame- tropia? 3. Will rendering the eye emmetropic contrib- ute in restoring the weakened muscle to its normal condition? The only difference between muscular asthen- opia and strabismus is that in insufficiency there is temporary inability to maintain binocular vision, while in strabismus the inability is constant. Mus- cular asthenopia implies an inability to bring both visual lines to bear constantly upon one point. In strabismus there is inability to bring both visual lines to bear upon one point at any time. In mus- cular insufficiency, then the muscle is partially disabled, and is enabled only a part of the time, and then with considerable effort, to perform its functions; while in strabismus it is totally dis- abled from performing these functions. We are fully cognizant of the influence of hyper- opia and myopia upon the induction and mainte- nance of convergent and divergent squint. Observant oculists have noted that from 75 to 85 ,per cent of all cases of convergent squint are hyperopic, and in the divergent there is even a larger per cent of myopia. This alone adequately demon- strates the influence of the ametropise upon the functions of the orbital muscles. As we all well know, it does not follow that all cases of hyperopia and myopia are the subjects of INSUFFICIENCIES OF THE OCULAR MUSCLES. 277 niuscular asthenopia, the occupations of the ame- tropic having much to do in developing this affection. In order that the eye may deviate from its nor- mal position, one of two conditions is necessary: there must be a physical or functional weakness of one muscle, or set of muscles, from which the eye is deflected, or an excessive strength of a muscle or set of muscles, toward which it becomes directed. In simple hyperopia and myopia how is this accomplished? The Modus Operandi. — In hyperopia the pa- tient is compelled to accommodate in order to focus the rays of light upon the retina and make the image more distinct. The greater the degree of h^^peropia the more he is compelled to exert his accommada- tion. Accommodation produces convergence, and the long continued effort of accommodation for this reason makes the convergence permanent. In a few cases of hyperopia the muscle is not able to stand the long continued strain at con- vergence, and in order to avoid confusion of images or diplopia, the eye is instinctively turned out and entirely away from its fellow. Thus in hyperopia we occasionally have a divergent squint. In myopia, as is well known, the patient sees well and often without effort of accommodation, when the object is brought to a very near point; hence, in order to obtain binocular vision, one or both eyes must become abnormally converged. The greater the degree of myopia, the more con- 278 TEXT -BOOK OF OPHTHALMOLOCxY. vergence is necessary in order to maintain binocular vision. The effort being irksome, and the work too fatiguing to accomplish with both eyes simultane- ously, as is especially the case Avhen there is much near work to perform, one eye is disregarded and in- voluntarily turns out, far enough aAvay from its fel- low, that there may be no confusion of images. In those cases of myopia which are accompanied by convergent squint, the myopia is usually of small degree, and the amount of convergence is not so great but that the internal recti muscles may become ortho- psedically trained and strengthened by use for near work. In this case it is usual for one eye to become permanently convergent, and able to perform only near work, while it entirely disregards objects for a far point. As myopia is the most common cause of diver- gent squint, it is evidently the greatest factor in tlie cause of insufficiencies of the internal recti muscles. Myopia is real or factitious. It is real if, when there is complete relaxation of the accommodation, the measurement shows that the retina is situated behind the principal focus. It is factitious or forced myopia, if the ciliary muscle is cramped in such a manner as to cause the crystalline lens to become so convex that parallel rays of light in passing through, meet before reaching the retina. This con- dition, as we all know, is frequently acquired in eyes that are emmetropic, and even in small degrees of hyperopia. INSUFFICIENCIES OF THE OCULAR MUSCLES. 279 So far we have had imder consideration the causes wherebj^ tlie muscles have become perma- nently deranged, so that we may b(» more thoroughly equipped for the discussion of that other condition of the ocular muscles wherein they become tempor- arily unable to perform their functions. Now it is a matter of very little importance whether the eye is really or factitiously myopic, or is hyperopic, the conditions for the production of weak internal recti muscles are exactly the same; that is, in myopia, to recapitulate, the patient must place the object close to the eye in order to obtain binocular vision. The greater the degree of myopia, the more convergence, and the more constant the effort at convergence the more strain on the internal recti muscles; hence the asthenopia. In hyperopia the patient accommodates to cause the lens to become sufficiently convex to focus the rays of light upon the retina. As accommodation causes convergence, the more he accommodates the more he converges, and the greater the strain upon the internal recti muscles. We can converge without accommodating, but cannot accommodate without converging. If the patient could accommodate without converging, then there would be no strain upon these muscles, hence no asthenopia in hyperopia. As heretofore mentioned, the internal recti mus- cles are most frequently affected with the inability to properly perform their functions; although the 280 TEXT -BOOK OF OPHTHALMOLOGY. external recti muscles are occasionally thus affected. This condition is produced in one of two ways: either, first, by a permanent contraction and increased strength of the internal rectus orthopsedically ob- tained — that is, acquired by moderate and continued effort at convergence; or second, by a spasm or cramp of the internal rectus caused by an over-ex- ertion of that muscle. In either case the result is the same; the external rectus is weakened by the long continued strain upon it. I am now confident that this cramp or spasm from overworked muscles plays a very important part in the production of insuflSciencies, and I am also sure, because I have seen it practically demon- strated, that spasm of the ciliary muscle is an equal, or perhaps the most important factor in the devel- opment of muscular asthenopia. A muscle will not become weak without a cause. Even if it becomes cramped and spasmodically con- tracted (functionally strengthened), it is an evidence of weakness and not of tone. Cramp or spasm is a result of its weakened and overworked condition; and for this reason I believe there are very few cases of insufficiency without an error of refraction, either real or factitious; and the forced error is certainly the more productive of this condition. Let us inquire how this may be accomplished. Martin, I believe, advanced a theory of segment- ary or unsymmetrical or, in other words, irregular contractions of the ciliary muscles, whereby the lens INSUFFICIENCIES OF THE OCULAR MUSCLES. 281 became irregularly curved or astigmatic. We have good reason for believing that the theory is correct. We have all of us seen eyes which have presented all the evidences of astigmatism, simple, compound, mixed, or irregular, which, after the accommodation had been thoroughly suspended under atropine, have been found to be emmetropic. Now there was a functional defecl: somewhere before the accommo- dation was suspended, and that defect could have been in but one place — the crystalline lens. Moreover, we occasionally meet with cases that do not show any evidence of astigmatism until after the accommodation is suspended. In these there is corneal astigmatism which has been compensated for in the lens by its assuming such a shape as to cor- rect the corneal irregularity. Bonders was the first, I believe, who brought to notice this condition. We are taught that the macula lutea receives the impressions of images, and that it is the "sensi- tive point," that the images received at other points of the retina are not so distinct, hence it is the effort of the orbital muscles to so balance the eye that the impressions may be received on this particular point. We know the influence upon the ocular muscles where there is a clear spot of cornea on an extensive opacity. The eye involuntarily assumes that posi- tion in which the rays of light will best be received on this particular portion of the cornea, so as to fall as nearly as possible upon the yellow spot and thus secure the best possible vision that can be obtained 282 TEXT -BOOK OF OPHTHALMOLOGY. under the circumstances. So also in other cases,. where there is from any cause a removal of the pupil from behind the center of the cornea to some other position, the eve adapts itself to that position in which it can receive the best vision. To do this one muscle or set of muscles becomes strengthened, and their antagonists correspondingly weakened. Now we know that any abnormal change in the curvature of the crystalline lens will change the angle of vision and, upon the same principle as in corneal opacities and abnormal positions of the pu- pils, disturb the equilibrium of the eye by its influ- ence upon the ocular muscles. If, then, certain changes in the curvature of the crystalline lens are productive of insufficiencies of the internal and external recti muscles, certain other changes will also account for insufficiencies of the superior and inferior recti. To summarize thus: When an eye turns in, or out, or up, or down, or in any manner away from its normal position, there is one of two conditions exist- ing. It does so either to place itself in such a posi- tion as to receive a better retinal image, and thereby assist both eyes to bear upon the same point; or to place itself in that position in which binocular vision will be entirely disregarded in order to avoid the con- fusion of images. My experience has taught me that the low de- grees of ametropia are, perhaps, more fruitful in the causation and maintenance of muscular asthenopia INSUFFICIENCIES OF THE OCULAR MTSCLES. 283 than the hioh, because of the strained effort to main- tain binocular vision; for as heretofore explained, in th(» hi<>h degrees one e^^e is disregarded and the patient uses the other, while in the low degrees binocular vision can be maintained with some effort, which, however, if too steadily persisted in, produces fatigue. From this consideration of the subject, the con- ditions w^hich contribute to insufficiencies may be summarized as follows: Myopia, hyperopia, astig- matism and overw^ork, the latter being the exciting cause, which is more or less augmented by addi- tional refractive error. In considering the conditions which tend to the abnormal change of the visual angle, it would seem that the punctum saUens in the treatment of insuffi- ciencies of the internal recti, is to prevent great and long: continued efforts at convergence, and thus re- lieve the inordinate contractions of these muscles. Nothing will contribute so much to this purpose as remedying any refractive error, and thus rendering the eye as nearly emmetropic as possible. The indications for treatment must necessarily be brief. Although not entirely ignoring operative pro- cedures, it must be acknowledged that tenotomies have not afforded the brilliant results so ardently claimed for them by their supporters. A tenotomy is prejudicial for one very serious reason: the move- ment of the eye is curtailed, and if the operation is 284 TEXT -BOOK OF OPHTHALMOLOGY. successful in effecting fusion of images at a near point, there is usually too much restriction of motion for a distance, hence an annoying diplopia follows, which for persons engaged in the ordinary pursuits of life is much worse than the insufficiency. I am seriously impressed that operative proced- ures should be a dernier ressort, when all other means have failed — then advancement of the weak muscle, instead of tenotomy of the strong. There is not then the risk of diminishing the movements of the eye. My experience has induced me to believe that there is a very intimate relation between spasm of the ciliary muscle and insufficiencies of the orbital muscles. I rarely now make an examination for re- fractive error, without making the test for insuffi- ciency, and I have been surprised at the frequency with which I have met this affection. Although insufficiency of the internal rectus is far the most frequent, yet the test will frequently disclose it in the other orbital muscles, and especially in the superior and inferior recti. The examination now referred to is rather a pre- liminary inspection, for we can rarely determine cor- rectly the refractive condition of an eye without its thorough atropinization. The accommodation re- quires to be thoroughly suspended before an attempt is made at correction with glasses. This is import- ant, whether there appears to be an insufficiency or not in connection with the refractive error, for STRABISMUS. 28^ the reason that after the eyes are thoroughly atro- pinized we usually find them in a very diffc^rent con- dition from that shown at the preliminary examina- tion. What was then regarded as myopia, now turns out to be emnu^ropia, or perhaps hyperopia. What appeared a well-marked astigmatism is now neutralized, and insufficiencies frequently disap- pear. When we consider the close connection which exists between the eye and the brain, we cannot wonder at the numberless forms of nervous sensa- tions and irritations which may result even from a slight ocular defect. The act of seeing is a very com- plex performance, requiring and exacting for its ac- complishment the harmonious coordination of a number of cerebral nerve centers; the second, third, fourth, and sixth, and the sympathetic nerves, in- dividually and collectively, take a part in the per- formance of this function, the least defect in any one of which w^ill prevent that concordant unity of action designed by nature. Strabismus. The causes for insufficiencies of the external muscles of the eye have been fully discussed under the heading of the "Ametropise and their Eelation to Insufficiencies of the Recti Muscles." The operation for strabismus, when it becomes necessary to make it, is performed as follows: A fold 286 TEXT -BOOK OF OPHTHALMOLOGY, of the coujunctiva, near the margin of the cornea, and over the insertion of the tendon of the muscle to be divided, is siezed by a small pair of toothed forceps, and is snipped by a small pair of blunt pointed scissors. Immediately, the capsule of Tenon Figure 43. CAfter Meyer which lies under the loose conjunctival tissue, is also siezed with the forceps and snipped with the scissors in the same manner as was the conjunctiva. The strabismus hook is now introduced and passed under the tendon. The conjunctiva over the point of the hook should be gently pushed back with the scissors, or some other convenient instrument, until its point is brought through the Avound. We have now within the curve of the hook the tendon, which is divided with one snip of the scissors. After this has been done, the hook should again be introduced in order to ascertain if the tendon has been com- pletely divided. If a few fibres should remain un- divided, the operation may prove, on this account, very disappointing. RKFR ACTIVE ERRORS. 287 It is unnecessary to unite the conjunctiva with sutures. The only treatment necessary after this opera- tion is to bathe the eye frequently with iced water that has previously been sterilized. It is unnecessary to place the patient under the influence of ether previous to the operation except in case the subject is very young. When the ether is not used, the eye should be thoroughly cocainized previous to the operation by instilling into it a few drops of a four per cent solution of cocaine every two minutes for the period of a quarter of an hour. SECTION III. Methods of Detecting and Correcting Re- fractive Errors. Notwithstanding the perfection which has been attained in a knowledge of the irregularities in the refraction and accommodation of the eye, yet a greater interest should be had by the general prac- titioner in a subject which has so much to do in augmenting the functions of one of the most import- ant organs of the special senses. There certainly seems to be a want of concern among physicians generally of those affections at- tributable to defects that are capable of correction with the aid of glasses, and too often they are con- 288 TEXT -BOOK OF OPHTHALMOLOGY. sidered of such insignificant importance as to be referred for correction to the jeweler, who makes some pretensions as an optician, or to the spectacle vender. The eye presents many difficulties of stud}^ es- pecially that department which relates to departures from its normal refraction, owing to the necessary knowledge of optical principles, without which it is impossible to comprehend the abnormalities to which it is liable. It is not expected of, nor is it possible for the general practitioner to know all about optics, nor is it necessary for him to know more than is taught of refraction and accommodation in standard works on physiology, to measure the length of the eye and estimate the irregularity in the curvature of the cornea, and in many cases adapt suitable glasses to these conditions. A normal eye possesses in a wonderful degree the power of adjusting itself to view objects at dif- ferent distances, but when it becomes embarrassed, as is too frequently the case, by certain abnormal- ities in its anatomical structure, bv beino- too long:, or too short, or in having an irregularity in the curvature of the cornea (which in the main con- stitute the errors of refraction), it is limited in its functions to such a degree that it is exposed to con- tinual strains upon which depend so many of those distressing symptoms too frequently attributed to obscure nervous affections. REFRACTIVE ERRORS. 289 In order to appreciate the cause of a great many of these anomalies in its refractive power, we should impress ourselves with the property of the eye to adapt itself to different distances — in other words, its accommodation — regulated by the action of the ciliary muscle, which controls the lens in such a manner as to make it more or less convex, accord- ing as we desire to view objects near or far. In old age, of course, this action is limited, as the lens becomes less flexible. It is the abnormal action of this muscle that plays such an important part in rendering indefinite and mystifying the refractive condition of the eye. In order to equip ourselves as thoroughly as pos- sible for detecting, as well as correcting refractive errors, we should remember, that the normal eye may, by reason of a spasm of the ciliary muscle, be- come seemingly abnormal in its refractive powers. The above is one of the most important things with which we should impress ourselves on this sub- ject, for it is through the ignorance or disregard of the above fact that so many people are suffering from the use of glasses that are not adapted to their eyes. Defective vision, due to irregularities in the re- fraction of the eye, may be summarized as follows: 1. Defective vision may be due to structural imperfection, as irregular curved surfaces, or too short or too great length of the eyeball. 2. To a loss of the accommodation power of the eye. 290 TEXT -BOOK OF OPHTHALMOLOGY. The structural defects in the refraction of the eye are hyperopia, myopia and astigmatism. Hiipcropia is that condition of the eye in which it is too short. Mi/opia is that condition of the eye in which it is too h)ng. Asticjinatism is that condition of the eje in which the cornea or the lens, or both, are irregularly, curved. Hyperopia and astigmatism, or myopia and as- tigmatism, may be present in the same eye. Loss of accommodation is due to loss of elastic- ity of the crystalline lens, or to a paralysis of the ciliary muscle. Presbyopia is that condition in which there is a hardening of the crystalline lens, due to age. General Considerations for the Fitting of Glasses. In determining the refractive condition of the eye, it is necessary to have an outfit of appliances, more or less complete for this purpose, consisting of a trial case, test types, astigmatic cards, etc. The trial case consists of a number of concave and convex lenses, either mounted or unmounted, single or in pairs, more or less complete as to the number of glasses employed, their variety in strength, etc. A very comj^lete case for the general practi- tioner is the Student's Trial Case, manufactured by CONSIDERATIONS FOR FITTING OF GI.ASSES. 291 Meyrowitz, New York City. It consists of the fol- lowing: 26 pairs convex spherical lenses, from .25 D. to 20. D. (2 to 144 inches) ; 26 pairs concave spher- ical lenses, from .25 D. to 20. D. (2 to 144 inches); 1 plane j^jlass; 1 opaque glass; 1 red glass; 1 green glass; 1 single-grooved trial frame. Figure 44.— Trial Case. The physician desiring a more complete case wall find all that can be desired in the Standard Trial Case, manufactured by the same firm, which contains the following: 30 pairs convex spherical lenses, from ,25 to 20. D. ; 30 pairs concave spherical lenses, from 292 TEXT -BOOK OF OPHTHALMOLOGY. .25 to 20. D.; 18 pairs convex cylindrical lenses, from .25 to 6. D. ; 18 pairs concave C3'lindrical lenses, from .25 to G. D. ; 12 prisms, i to 20 degrees; 4 plain colored glasses; 1 white glass; 1 half-ground glass; 2 metal discs, with stenopaic slit; 1 stenopaic disc, with hole; 1 solid metal disc; 1 improved adjustable trial frame, with revolving cells and graduated scales; 1 single-grooved frame. Figure 45 A. -Trial Case. For the purpose of simply determining whether an error in the* refraction of the eye exists, a very CONSIDERATIONS FOR FITTING OF GLASSES. 293 limited number of concave and convex lenses will suflic(\ Figure 45 B.— Trial Frame. As the testing of the eyes with a view of ascer- taining a proper glass for a refractive error is a mat- ter of great importance, we should not only be sup- plied with all of the necessary implements for de- termining an}^ condition of refractive error, but we should have a well-lighted room, of proper length and sufficiently retired, that the physician, as well as the patient will have nothing to attract his atten- ion except that at hand. The business of refracting eyes is such that no surgeon can perform this service with his oflftce filled with lookers-on, or even with one or two who persist in annoying him in asking the patient ques- tions while he is making the examination. They are usually friends of the patient, and continually persevere in "helping'^ 3^ou along, by saying "why that's a T,'' or "you called an O, C, or G,'' or "you move on the screen in a direction opposite to that in which the mirror is rotated. If this principle is applied to the human eye, and light reflected from the surface of a concave mirror is directed into the eye, on looking through the sight-hole of the instru- ment we percieve an illuminated area surrounded by a deep shade on the retina. But since the image- is seen through the media of the eye, the direction in which the image moves as the mirror is rotated will depend upon the refraction of the eye under exami- nation." With this explanation of the principles involved, the method is readily demonstrated. The mirror used may be plane or concave and has a small central sight-hole. Figure 50.— Plane Mirror for Retinoscopy. A shade is also necessary, which should fit over the lamp, and at a point opposite the flame is a hole through which the rays to be reflected by the mirror pass. The surgeon sits beside the light in such a RETINOSCOPY. 337 position that the ra^s emerging; from the aperture in the shade are rellected by the mirror into the patient's e^e. If the pupil is very small, it should be dilated with homatropine previous to the examination. Af- ter throwing the light into the patient's eye, by ro- tating the mirror in different directions, there will be seen movements of the light on the fundus oculi. The light should be thrown into the eye at an angle of about 15 degrees. If the mirror used is a plane one, the movement of the shadow will be found to be with the motion of the mirror in hypermetropia, emmetropia, and myo- pia of 1 D or less. In myopia of more than 1 D, the shadow moves against the motion of the mirror. If the mirror used is a concave one, the move- ment of the shadow will be found to be against the motion of the mirror in hypermetropia, emmetropia, and myopia of 1 D or less. In myopia of more than 1 D, the shadow moves with the mirror. The manner of examination is as follows: The trial frame is placed on the patient^s face and the movement of the shadow is noted. (A concave mir- ror of about a twenty-inch focus being used.) If the e^'e is myopic, the shadow will move with the mirror. Now by placing a concave lens in the frame and by increasing its strength each time until the shadow moves against the motion of the mirror, the degree of myopia can be found. 338 TEXT -BOOK OF OPHTHALMOLOGY. Thus, if it requires a — 4 D lens to make the shadow move against the motion of the mirror, the degree of myopia is 4 D. To this must be added — 1 D, because at this dis- tance of four feet the observer strains and thus adds about +1 D to his own eye. If it were possible for the surgeon to make the observation at about twenty feet, or to entirely relax his own accommodation, it would not be necessary to make this addition of — 1 D. As the shadow moves against the motion of the mirror in emmetropia, hypermetropia, and myopia of less than 1 D, it is necessary for us to determine which of these three conditions is present. In emmetropia, the shadow is very distinct and the light area is clear and bright with well defined borders, while in hypermetropia there is a blurry, crescentic shadow with indistinct borders. In hy- permetropia we begin with a +1 D and increase the lens until the shadow reverses its direction and moves with the mirror. In hypermetropia +1 D must be subtracted from the lowest plus glass which reverses the direction of the shadow, for the defect is over-corrected. If a +1 D will cause the shadow to move with the mirror and the direction of the shadow will be the same with a lens less than +1 D, then the eye is slightly myopic less than — 1 D. But if a +1D causes the shadow to move with the mirror and a lens less than +1 D causes it to move against it, it is emmetropic. RETINOSCOPY. 339 If there is a difference in the motion of the shadow in two opposite meridians, it is indicative of astigmatism. If it is simple or compound astigmatism, there need not be any great difficulty in determining the amount, but if it is mixed, it cannot be accomplished by this method. The best manner for ascertaining the astigma- tism is to correct each of the principal meridians separately with spherical lenses, after which you can calculate the compound lens necessary for the correction of both meridians. This method of determining the refraction of the eye is not practical, especially in the intelligent adult, and should be resorted to with children only, or those who are not well enough informed to read letters and appreciate the intensity of lines at dif- ferent angles. 340 TEXT -BOOK OF OPHTHALMOLOGY. CHAPTER XXn. SECTION I. Ophthalmoscopy. TT is well known that all of the rays of light that enter the eye are not absorbed, bnt that some of them are reflected back ont of the eye. These ra^^s that are reflected back out of the eye pursue the same course as that by which they entered. It will be readily seen that if the observer could place his e^^e in the direct path of these reflected ra^'S without interfering with the source of light, a view of the fundus oculi could be obtained. This difficulty was overcome by Hemholtz in 1851 by the invention of the ophthalmoscope. The ophthalmoscope, as invented by Hemholtz, consisted of several plates of glass held together by Figure 51. a frame. The rays from tlie light L (see figure) are reflected into the patient's eye by the plates at O. OPHTHALMOSCOPY. 341 •The rays being reflected back out of the e^'e from M, strike tlie plates at O, aud some of tliem pass on tlii'oiioli the phites to the observer's eye at a, and the point ni is made visible to the observer. Many improvements have been made on the ophthalmoscope since the days of Hemholtz, so that the modern instrument bears but little semblance to the one used in those days. Of those in use at the present day the Loring ophthalmoscope is one of the best aud consists of a tilting oblong mirror with a small central aperture through which the observer looks. The ophthalmoscope is provided also with a circular disc in which are placed concave and convex lenses of varying strength. This disc is so i)laced that it can be revolved by the finger during the ex- amination and thus brings before the observer's eye the desired lens. Figure r)2A.— Loring's Ophthalmoscope. The purpose of these lenses is to neutralize any error of refraction either in the observer or patient, or both, so that a good view of the fundus can be obtained. 342 TEXT -BOOK OF OPHTHALMOLOGY. Previous to an exainination with the ophthal- moscope, it is necessary to dilate the pupil with some mydriatic. The light should be placed behind the patient's head and on the same side as the eye to be examined, care being taken that the patient's eyes are in the shadow. The observer sits facing the pa- tient and gazing through the sight-hole of the oph- thalmoscope directs the rays reflected from the mir^ ror into the patient's eye. w Figure 52 B. There are two methods of examination with the ophthalmoscope, the direct and the indirect. The Direct Method. In this method of examination, the parts of the fundus are seen erect and magnified about fourteen or fifteen diameters. The observer places his eye very near to that of the patient, in order that a more extensive view of the fundus can be obtained. If a mydriatic has not OPHTHALMOSCOPY. 343 been used, the patient should be directed to h^ok into space so as to rehix his accommodation, and it is nec- essary for the observer to do likewise, for if either accommodates, the rays will be brought to a focus in front of the observer's retina, and in consequence a blurred image. This is one of the essential points in making an examination with the ophthalmoscope, and until the student can learn to relax his own ac- commodation, the results will be very unsatisfactory* Figure 53. On examining the figure, the formation of the image in this method can be readily apprehended. The rays reflected from the concave mirror O converge, and, on passing through the refractive media of the eye, become more convergent and focus in the vitreous humor and illuminate the retina from a to h. While some of these rays are absorbed, others are reflected back out of the eye from all points included between a and &, and if the pa- tient's eye is emmetropic, the rays from any i3oint, X, for instance, will become parallel on emerging from the patient's eye, and on entering the observer's eye focus at .x^ providing his eye also is emmetropic. 344 TEXT -BOOK OF OPHTHALMOLOGY. In like manner rays from .// become parallel and focus on the observer's retina at y^, while those from nt unite at ni^ in the observer's eye. If the patient's eye is hyperopic, the rays from the point x diverge on emerging from the eye and the observer, in order to render these rays parallel, must place a convex glass before his own eye. As the reflected rays are convergent in a myopic eye, the observer, in order to render these rays par- allel, must place a concave glass before his own eye. The Indirect Method. (Method of examining the inverted image.) In this method a more extensive view of the fundus is obtained than by the direct method, al- though the different parts appear smaller. The observer holds in one hand, between the thumb and index finger, a convex lens of about 16 D, close to the eye of the patient and steadies his hand by placing the remaining fingers on the brow of the patient. In the other hand is held the oph- thalmoscope, about two feet distant from the pa- tient's eve. Figure 54. THE NORMAL FUNDUS OCULI. 345 On examining- the fij^ure this method cau be readily understood. It will be seen that the convex lens condenses the rays of light from the mirror and brings to a focus the reflected rays emerging from the eye, thus form- ing an inverted, serial image of the fundus between the lens and the mirror. There are mam^ minor details with regard to the examination of the eye with the oj^nthalmo- scope, which are omitted for the reason that it is impossible to intelligently explain them, as this knowledge can be obtained only by a continued and careful practice with the instrument. SECTION II. The Normal Fundus Oculi as seen with the Ophthalmoscope. Its Color. The color of the fundus oculi varies in different races. Among the white races it has a reddish color, while in the dark races it is of a grey- ish hue. It also varies in different members of the same race, for in very fair persons the fundus is very light, while in dark persons it is correspond- ingly dark. This difference in color is due to the amount of pigment deposited in the choroid; thus in the fair races there is usually a Yerj scanty deposit of pigment, while in dark races it is very profuse. Owing to this profuse deposit of pigment in dark per- sons, the vascular structure of the choroid is with 346 TEXT -BOOK OF OPHTHALMOLOGY. difficulty discernible; on the other hand, in light complected persons, owing to the small amount of pigment, the choroidal vessels can be seen with ease. There is a congenital absence of this pigment in some people, which condition is known as alhwism, and persons thus affected suffer very much from the light. Its Si:^e. Owing to the magnifying powder of the refractive media of the eye, the fundus appears en- larged about fourteen or fifteen diameters. nasal f temporaP- Normal Fundus of tite IvEft Eye, seen in the erect Image. The optic disk, which is somewhat oval longitudinallj', has the point of entrance of the central vessels somewhat to the inner side of its center. That portion of the papilla lying to the inner side of the point of entrance of the vessels is of darker hue than the outer portion ; the latter shows, directly to the outside of the vascular entrance, a spot of lighter color, the physiological excavation with fine grayish stippling, representing the lacunte of the lamina cribosa. The papilla is surrounded, first by a light-colored ring, the scleral ring, and externally to this by an irregular black stripe, the chorioidal ring, which is especially well marked on the temporal side. The cen- tral artery and vein divide immediately after their entrance into the eve into an as- cending and descending branch, which appear somewhat lighter than their continu- ations upon the retina, because they lie in the depth of the physiological excavation. The branclws, while still on the papilla, split into a number ot smaller divisions and fine offshoots from them run from all directions tov^ard the macula lutea, which it- self is devoid of vessels, and is distinguished by its darker color. In its center a bright punctate reflex,/, is visible. Figure 55. (After Fuchs.) The Retina. The retina is not visible to the ob- server when the fundus is very light in color, but in cases where the deposit of pigment is great, it ap- pears as a cloud before the choroid. (The appear- THE NORMAL FUNDUS OCULI. 847 ante of the retinal vessels will be described in con- nection with the optic disk.) Macula Lutva or Yellow Spot. The macula lutea is found about two diameters of the disk to the outer side of the papilla, and on a level with a horizontal line draw^n through the disk slightly below its cen- ter. It is of about the same size as the optic disk and is darker in color than the rest of the fundus. The blood vessels of the macula lutea cannot be seen, but its circumference is bordered by minute branches of the retinal vessels, which are observ- able. At the center of the macula lutea, there is sometimes seen a small bright spot of a yellowish color. This is the focca centralis. (Nettleship has demonstrated by injection, that numerous capillar- ies occupy all parts of the macula lutea with the exception of the fovea centralis, which is entirely free from these capillaries). There are two factors that contribute to the formation of the yellow spot: first, a thinning of Jacob's membrane at this point for the reason that the rods are wanting; second, the optic nerve fibres are lacking here. The Optic Disl' and Retinal Vessels. One of the best descriptions of the general appearances of the optic disk and retinal vessels in the health}^ eye is given by C. Macnamara, F. R. C. S., in his "Diseases of the Eye," which was published in 1882. It is as follows: "The optic disk, or papilla, which is the termination of the optic nerve, or the spot at w^hich it expands into the retina, will be found about one- tenth of an inch internal to the axis of the eje; it is the first point w^hich attracts the observer's atten- 348 TEXT -BOOK OF OPHTHALMOLOGY. tion in making an examination with the ophthalmo- scope. The shape of the healthy papilla is gener- ally circular, but it frequently appears oval, because the optic nerve and papilla are inserted sideways into the eye, and we see it more or less obliquely, and consequently, it is shortened in its horizontal diameter. In other cases this oval form is due to a real irregularity of the optic nerve, or to an irregu- larity in the dioptric media, notably in astigmatism. The size of the optic disk is by no means the same in all cases, and will appear to be augmented or les- sened according to the powder used to magnify it. The color of the disk is not uniform, its outer part being grayish and mottled. This appearance is caused by the difference in the light reflected from the nerve tubules, which is grayish, and that from the white, glistening bands forming the lamina cri- brosa. At the point of exit of the retinal vessels the white appearance is very marked, and often presents a little pit or hollow. The inner half of the disk is of a decidedly redder tint than the outer half, be- cause it is more thickl}^ covered by vessels and nerve fibres, and hence there is no reflection from the fibres of the lamina cribrosa in this situation. It is absolutely necessarj^ to become acquainted with the different appearances which may be presented by the healthy optic disk, or these varying condi- tions may be mistaken for indications of disease; the outer grayish-white tint, the central depressed appearance and whitish hue, together with the inner pinkish half of the disk, are conditions which vary THE NORMAL FUNDUS OCULI. 349 considerably, but are more or less distinctly recog- nizable in all health}' eyes. At the point where the lamina cribrosa ceases, the optic nerve is contracted, and the opening in the choroid being narrow, in a certain measure com- presses the nerve trunk; for this reason a sort of double border is often seen around the margin of the optic papilla. Under the choroidal margin is the line, more or less dark, that indicates the border of the opening in the choroid; under the sclerotic margin is a bright crescent or circle, formed by the curving round of the sclerotic fibres, and appearing between the choroidal margin and the fine grayish line that indicates the narrowc^st part of the nerve itself, and is therefore called the proper nerve bound- ary. The latter under normal circumstances, is not usually sharply defined. The choroidal rim is al- ways strongl}^ marked, especially at the outer bor- der of the disk, where it sometimes has a well-defined deposit of pigment; this must not be mistaken for a diseased condition of the parts. The point at which the central artery and vein of the retina enter the eye through the optic disk is subject to considerable variation. Generally the artery passes through the whitish and depressed cen- ter of the papilla, and, after emerging from the disc divides dichotomousl}^, its branches ramifying in all directions toward the periphery of the retina; but the central artery m.ay perforate the disc at any other point; not unfrequently one or two larger branches are noticed in the center of the papilla. S50 TEXT -BOOK OF OPHTHALMOLOGY. while others pass through its circumference, per- haps close up to the scleral margin of the disc. The apparent calibre of the vessels will vary with the magnifying power employed in observing them; practice alone will thus enable us to appre- ciate abnormal changes in the calibre of these ves- sels. One frequently reads accounts in which the retinal vessels are said to be over-full or empt}^, as the case may be; but in truth it is most difficult to determine this point. The arteries, as well as their branches, are thin- ner, lighter in color, and straighter than the veins, which are darker in color and more sinuous in their course. The arteries seem to be transparent in their centers. This arises from the difference in the de- gree of illumination of the prominent centers of the arteries, as contrasted with their sides; from their conformation, it is evident that the sides of a vessel would receive and reflect relatively less light, and therefore appear in shade. If in the normal eye the central vein be care- fully examined, a pulsation may often be noticed in it, which will be rendered more evident on gentle pressure being made on the eyeball. If the com- pressing force be increased beyond a certain point, the pulsation at once stops, and the veins become almost invisible from the cessation of the flow of blood through them. In the healthy eye no arterial pulse can be seen, but if pressure be made on the eyeball it will become apparent. We noticed this in a marked manner in cases accompanied with con- THE NORMAL FUNDUS OCUU. 351 siderable intra-ociilar pressure, as for instance, in glaucoma. The small depression on the surface of the disk is called the ph^-siological excavation, in order to distinguish it from the pathological depression which is sometimes due to an abnormal intra-ocular pres- sure, as in glaucoma, or to atrophy of the optic nerve fibres." 352 TEXT -BOOK OF OPHTHALMOLOGY. CHAPTER XXni. The Perimeter. CHE perimeter is an instrument used to deter- mine the dimensions of tlie field of vision. The field of vision (visual field) is that portion of space containing all the points that are visible to the eye remaining fixed in one position. Emerson's perimeter (a cut of which is given) is one of the best and is thus described: Figure 5G.— The Perimeter. "The arc is a semicircle of 12.7 C. M. (5 inches) radius, revolving on a hollow spindle, and is divided on its convex surfact' into eighteen equal parts, num- THE PERIMETER. 353 bered from the center to the extremities. On each arm of the arc is a perforated slide, so made that small pieces of paper can represent the objective point; in testing the color zones colored paper can be used. The arc is supported by a quadrant, mounted upon an adjustable upright set in a firm brass base. The scale on which the angle of revolu- tion is measured is fixed to the quadrant, and a pointer attached to the revolving arc indicates the meridian tested. The chin rest is double, the right for the left eye and vice versa. The eye of the person tested should be 12.7 C. M. (5 inches) from the aper- ture and on a level with it." The method of examination is as follows: Be- fore making the examination it is necessary to bandage or cover the eye that is not being tested. The patient having placed his chin on the rest, he is directed to look at the fixation i^oint which is sit- uated at the midle of the semi-circle. We will sup- pose the semi-circle to be in a horizontal position. The perforated slide to the right is now moved slowly from the extremity towards the center of the semi-circle. At the instant the patient discerns the paper in the slide the point on the convex sur- face at which the slide stops is recorded on the peri- meter chart. In the same manner the slide to the left is moved toward the center and the point at which it is first discerned is recorded on the chart. We now revolve the semi-circle a few degrees (say 30 degrees) and proceed as w^e did w^hen the semi-circle was horizontal. 354 TEXT- BOOK OF OPHTHALMOLOGY. Ill like manner we revolve the semi-circle the same number of degrees each time and record the points at which the slide becomes visible. By con- necting the points thus recorded on the chart, the field of vision is found. Having obtained the field of vision of this eye, we proceed in like manner to find the visual field of the other eye. Where a Avhite paper is used in the slide, the field of vision is largest. Where the different colors are used, the field decreases in size in the following order: blue, yellow, orange, red and green, green having: the most limited field. /?.£: «?'»'' EMERSON SI^ERIMETER CHART mevrowitz bros. n.y. Figure 57. On examining the accompanying charts, it is; seen that the field of vision is not circular but of an irregular shape, extending upward about 50 degrees, outward somewhat over 90 degrees, inward 45 de- grees, and downward 65 degrees. Owing to the pro- jection formed by the nose inward and the supra- THE PERIMETER. 355 orbital margin aboA^e, the field of vision inward and upward is not as extensive as that of the temporal side. The hrutd spot is the papilla which marks the entrance of the optic nerve and is so called because it cannot appreciate visual impressions. Corresponding to the blind spot is a small island or scotoma in the field of vision situated 15 degrees to the outer (temporal) side of the fixation point. The perimeter is of value in determining the size and position of a scotoma. A scotoma is positive when it is apparent to the patient as a dark area in the field of vision. In a negative scotoma, objects simply disappear when within the limits of the scotoma. A central scotoma is one that occurs at the point of fixation and is due probably to a lesion of the optic nerve or macula. Annular scotoma is one that surrounds the point of fixation and is circular. ^Scotoma scintiUans appears as a luminous cloud or mist before the patient's eyes. When it has an irregular outline like that of the w^all of a fort, the condition is knowm as teichopsia. The condition in which one-half of the field of vision is absent is called hemianopsia. Temporal hemianopsia is that condition in which the temporal halves of both visual fields are absent. Nasal hemianopsia is that condition in w^hich the nasal halves of both visual fields are absent. 356 TEXT -BOOK OF OPHTHALMOLOGY. Honionoyiiioiis or equilateral hemianopsia is that condition in which the temporal half of one visual fiekl, and the nasal half of the other are wanting. Placido's Disc. Figure 58.— Placido's Disc. Placido's disc is an instrument used to deter- mine in a short time whether astigmatism is present. It consists of a disc about ten inches in diameter and has a central aperture w^hich is used as a sight- hole for the observer. On the disc are concentric circles of a dark color, the background being white. The observer gazing through the sight-hole, holds the instrument about ten inches from the eye of the patient and sees the circles reflected on the cornea of the patient. If the circles are distorted, astig- matism is present. This is an exceedingly simple test and can be used by any physician. OPHTHALMOMETRY. 357 Ophthalmometry. The ophthdJmoinvtvr is an instrument for deter- mining the amount of astigmatism by examination of images reflected from tlie surface of the cornea. The description of the instrument and the method of examination as given by Gertrude A. Walker, M. D., of Philadelphia, in her "Students' Aid in Ophthalmology," is one of the best, and is as follows: "A telescope is supported by an up- right bar with a movable tripod base. Within the telescope at the focus of the eye-piece are two fine cross hairs; the telescope is also ful^nished with a Figure 59.— Javal-Schiotz Ophthalmometer. bi-refrigerant prism. To the large end of the tele- scope is attached a graduated arc, upon which are 358 TEXT -BOOK OF OPHTHALMOLOGY. Iavo objects called targets, or mires, one of these (the left) being fixed, while the other is movable. Each target is a parallelogram in shape, but one is cut away in steps. (See Fig. 60.) At the outer side of each target is a small pointer. A much larger pointer is attached to the telescope at about its center. The telescope passes through the center of a large graduated disc. Opposite the telescope is a rest for the patient's head, and a small shade which is used to cover the eye not under examina- tion. In testing, the ophthalmometer should be so Figure 60. placed that a strong light falls upon the disc. The patient's head having been placed in position, the eye to be tested should look into the telescope. The observer now brings the patient's eye into the field of the telescope and into focus by moving the tripod Figure 61. Figure 62. base of the instrument backwards and forwards. The targets and the disc are now reflected upon the OPHTHALMOMETRY. 369 patient^s cornea. Because of the prism in the tele- scope, there appear to the observer's eye four im- ages of the targets. The outer ones are to be dis- regarded. The telescope should now be rotated so as to bring the long pointer to the zero mark on the disc. The left target is now brought into the center of the field, so that the cross hairs seem to divide it into four equal parts. Then the second target is made to slide along the arc until its edge seems just to touch, but not to overlap that of the first one. (See Fig. 61.) The telescope should now be slowly rotated. If astigmatism be present, the target images will either separate or overlap. (See Figs. 60, 62.) The point of greatest separation or overlapping is found and the graduation upon the disc as indicated by the large pointer is noted. This expresses the direction of one of the principal meridians of the cornea. The extent of the separation or overlapping indicates the amount of astigmatism, each step of the target image being equivalent to one diopter. The extent of overlap- ping or separation is best found by noting the num- ber of graduations that are passed over when the target is moved along just far enough to bring the edges of the two images together as at the begin- ning of the test. In case of overlapping, the small pointers indicate the meridian of greater curvature, while in case of separation they indicate the meri- dian of less curvature." 360 TEXT- BOOK OF OPHTHALMOLOGY Figure Co— Double I'ixation Hook. Figurk d I. —Beers' Cataract Knife. ^ FiGfRK (■;.").— Levis' Lens Scoop Figure 6G. — Lens Scoop. Figure 67.— Curved Cataract Needle. Figure 68.— Knapp's Needle Cystotome. Figure 69.— Dix's Spud. Figure 70.— Beers' Cataract Needle. Figure 71. — Stevens' Tenotomy Hook. Figure 7'2.— Payne's Pterygium Knife. MEYR0WIT2. Figure 73.— Gruening's Cautery Probe. MEYRCWITZ Figure 74.— Strabismus Hooks. Figure 75.— Knapp's Cystotome. ^^ MEYROWTIZ. Figure 76.— Keratoraes. ILLUSTRATIONvS OF INSTRUMENTS. 361 MEmOWlTZ. Figure 77.— Paracentesis Needk Figure 79.— Curved Scissors, Blunt Point. Figure 80.— Stevens' Tenotomy Scissors. Figure 81.— Curved Iris Scissors. Figure 82.— Manoir's Scissors. 362 TEXT -BOOK OF OPHTHALMOLOGY. Figure 84.— Noves' Iris Scissors. Figure 85.— Wecker's Iris Scissors. Figure 87.— Cilia Forceps. ■nr^ Figure 88.- Fisher's Iris Forceps, Figure 90.— Dressing Forceps. ILLUSTRATIONS OF INSTRUMENTS. 363 Figure 91.— Desmarre's Entropium Forceps. Figure 92.— Bowman's Lachrymal Probes. Figure 95.— Stevens" Tenotomy Eye-Speculum. Figure 96.— Universal Eye-Speculum. 364 TEXT -BOOK OF OPHTHALMOLOGY. Figure 97. Strabismometer. Figure 98. Andrews' Aseptic Syringe for Anterior Chamber. Figure 99. Aseptic Atropine Dropper and Bottle, Figure 100.— McCoy's Aseptic Eye Shield Figure 101.— Andrews' Eve Shield. GLOSSARY. ABDUCENS OCULI {ab-du'-senz ok'-yii-li). The rectus oculi ex- ternus muscle ; also a nerve supplying the rectus oculi externus. ABERRATION, {ab-er-a'-shtin ) OPTICAL. A scattering of the rays of light passing through a lens, so that they fail to unite at a focus. ABLATIO RETINA {ab-la'-she-o ret'hia). A detachment of the retina. ABLEPHARIA [ah-blef-ai-'-e-ah). A total or partial absence of the eye-lids. ABLEPSIA [ah-blep'-se-ah). Want of sight ; blindness. ABRASIO-CORNEA {ab-ra'-ze-o kor'-ne-ah). A shaving or scraping off of superficial opacities from the cornea. ABRIN {a'-brin). The active principle of jequerity, ABSL'S {ab'-sus). A mixture composed of powdered cassia seeds and sugar, used in Egypt for the treatment of ophthalmia. ACCOMMODATION [ak-kom-mo-da'-shim). The act by which the eye is adjusted for different distances. Positive a., is the adjustment of the eye for near points. Negative a., is the adjustment of the eye for distant points. Region of a., is the linear distance between the far -point and the near-point. Range of a., is the change in the refractive condition of the eye produced by the accommodation. Spasm of a., is a continuous spasmodic cramp or contraction of the ciliary muscle, producing increased convexity of the crystalline lens, and making the eye appear to have a higher refractive power than it really possesses. ACHLOROPSIA (a/^-z^/^r-c'/'-^^-^.^). Green blindness. ACHNE {ak'-7ie). A flake of mucus-like substance on the cornea. ACHROMATIC LENSES {ah - kro -mat'-ik tenses). Those con- structed of a combination of crown and flint glass, so arranged as to obviate chromatic aberration. ACHROMOTOPSIA {ah-kro-mat-op'-se-ah). Total color blindness. ACUS OPHTHALMIA {a'-kus of-that'-me-ah). A couching or oph- thalmic needle. ACYANOBLEPSIA {ah-si-an-o-btep'-se-ah). The inability to distin- guish blue. ADACRYA [ah-dak' -re-ah) . A deficiency of the lachrymal secretion (365) 366 TEXT -BOOK OF OPHTHALMOLOGV. ADDUCENS OCULI {ad-du'-senz ok'-yu-li). The rectus oculi internus. ADENOPHTHALMIA [ad-en-off-thal'-me-ah). An inflammation of the meibomian glands. ADVANCEMENT {ad-vans' -ment) . Is an operation in which the tendon of a rectus muscle is brought forward to a new attach- ment. AEGILOPS {e'-ji-lops). A fistulous ulcer under the inner angle of the eye. AFTER CATARACT {aft'-er kat'-ai^-akt). Portions of the capsule and lens remaining after extraction. AGLIA {ag'-le-ah). A whitish speck on the cornea. AKYANOPSIA {ah-ki-aft-op'-se-ah). Violet blindness. ALBUGO [al-bu'-go). A white opacity of the cornea. The same as leucoma. ALLOCH ROM ASIA [al-o-kro-ma-ze'-ah). A difi"erence or change in color. ALTERNATING SQUINT {awV-ter-nat-ing squint). The condi- tion obtaining when the two eyes squint alternately. AMAUROSIS {am-aw-ro'-sis). A loss of sight without perceptible ocular lesions. AMBLYOPIA {am-ble-o'-pe-ah). A dimness of sight; particularly weak vision unaccompanied by organic changes in the eye, and not benefitted by glasses. AMETROMETER {ah-met-rom'-et-er). An instrument for measur- ing ametropia. AMETROPIA {ah-met-ro'-pe-ah). A condition of the eye in which the refracting powers of the media are not adjusted to the posi- tion of the retina. ANERYTHROPSIA {an-er-ith-rop' -se-ah) . Red blindness. ANGLE-ALPHA {ang'-gel al'-fa .) The angle formed by the line of vision with the major axis of the corneal ellipse. Gamma a., the angle formed by the line of fixation with the axis of the eye. Convergence, a. of, measured by the angle through which an eye turns when it abandons parallelism to fix a near object. Incidence, a. of. The angle made by an incident ray with the per- pendicular. Refraction, a. of. The angle formed by the refracted ray with the perpendicular. Vision, a. of, is the angle between the two lines drawn from either extremity of an object to the eye. ANIRIDIA {an-ir-id'-e-ah). Absence of the iris. ANISOCORIA {an-is-o-ko'-re-ah). Inequality of the pupils. ANISOMETROPIA {an-is-o-me-tro-pe-ah). The state in which the refraction of the two eyes is unequal. GLOSSARY. 367 ANKYLOBLEPPIARON {an_Q;-ki/-o-blef'-ar-on). A total or partial adhesion of the borders of the lids. ANNULAR MUSCLE OF MULLER {cui'-u-lar inus'-l of Mueller). A portion of the ciliary muscle. ANOPHTHALMOS {an-off-thal'-mus). Absence of the eye. ANOPSIA {a?i-op'-se-ah ). Defect of sight ; especially poor sight due to defectiveness of the eye. ANORTHOPIA [an-or-tho'-pe-ah). A natural defect of sight in which one is unable to detect a want of symmetry. ANTERIOR CHAMBER {an-te'-re-or cham'-ber). The space be- tween the posterior surface of the cornea and the anterior sur- face of the lens. ANTIMETROPIA {an-te-met-ro'-pe-ah). That condition in which one eye is hyperopic and the other is myopic. APHAKIA {ah-fa'-ke-ah). The condition of an eye without the crystalline lens. APLANATIC [ah-plan-at'-ic). Unaffected by spherical aberration. AQUEOUS HUMOR {a'-kzve-us u'-mor). A colorless fluid in the an- terior and posterior chambers of the eye. AQUULA [ak-ivu'-lah). An aqueous or fatty tumor under the skin of the eye-lids. ARCUS vSENILIS [ar'-kiis se-ni-lis). A narrow gray line of degen- eration which runs around the cornea; due to deposition of col- loid material. ARGYRIA [ar-jir'-e-ah). A deposition of silver oxide in the tissues of the conjunctiva. ARTERY HYALOIDEA {ar' -ter -e hi- al -old' -e -ah). The artery which nourishes the vitreous and lens in the fetus. It runs an- tero-posteriorly through the vitreous humor. It disappears usually after birth but in some instances persists. ARTIFICIAL EYE [ar-te-fish'-al i). An eye made of glass or cellu- loid. ARTIFICIAL PUPIL [ar-le-fish'-al pu'-pil). The result of an opera- tion for overcoming the effect of adhesions or permanent con- traction of the iris. ASTHENOPIA {as-then-o'-pe-ah). Rapid tiring of the eyes upon ex- ertion, manifested by a sense of pain in the eyes, headache, am- blyopia, etc. Acconnnodative a. Is due to fatigue of the ciliary muscle owing to excessive strain required by the presence of a refractive error, as hyperopia or astigmatism. Muscular a. Is due to insufficiency or weakness of the muscles of the eye. Nervous a. Is due to central causes, such as hysteria. ASTIGMATISM {as-tig' -mat-ism). A condition in which the re- fractive power of the eye varies in the different meridians, so that 368 TEXT -BOOK OF OPHTHALMOLOGY. the rays which enter it along one meridian are brought to a focus sooner than those which enter it along another. This condition makes lines running in all directions appear different, although they are alike. Simple a., is that condition of the eye in which it is emmetropic in one diameter and hyperopic or myopic in the other me- ridians. Compound a., is that condition of the eye in which there is hy- peropia or myopia in all meridians, but more so in some than in others. Mixed a., is that condition of the eye in which there is hypero- pia in some meridians and myopia in others. Regular a. is that form of astigmatism in which is found one meridian of greatest and one of least refraction, which two meridians usually lie at right angles to each other, which meridians are known as principal meridians. Irregular' a, is that form in which the unequal curvatures of the cornea bear no constant relation to each other; therefore there are no principal meridians. Corneal a. is caused by irregularity of the curvature of the cornea. Lenticular a. is caused by an irregularity of the curvature of the lens. ASTIGMOMETER {as-tig-mom' -et-er). An instrument for locating and measuring astigmatism. ATROPINE or ATROPIN [at'-ro-pin). An alkaloid of belladonna used as a mydriatic. AUTOPHTHALMOSCOPY [aw-toff-thal'-ino-skop-e). The use of the ophthalmoscope on one's self. BASEDOW'S DISEASE ( Ba'sedow's dis-ez' ). Exophthalmic goitre. It is so called from Basedow, who described it in 1840. BINOCULAR [bin-ok'-u-lar). With, or by means of both eyes, as binocular vision. "BLACK EYE" [black-i). Ecchymosis of the eye-lids. BLEAR EYE. A chronic inflammation of the eye lids. Marginal blepharitis. BLENNOPHTHALMIA {blen-off-thal'-me-ah). An inflammation of the mucous membrane of the eye accompanied by a purulent or muco-purulent discharge. BLEPHARADENITIS {blef'-ar-ad-en-i-tis). An inflammation of the meibomian glands. BLEPHARITIS [blef-ar-i'-Hs). An inflammation of the eye-lids. BLEPHARITIS MARGINALIS {blef-ar-i-tismarj-iii-al'-is). (Bleph- aradenitis; blepharitis ciliaris) a chronic diffuse inflammation of the sebaceous glands along the margins of the lids. GLOSSARY. 369 BLEPHARO-ADENITIS {hlcf -ar-o - ad-en-i-tis) . Same as bleph- aradenitis ; blepharitis marginalis. BLEPHARO- ADENOMA {blef-ar-o-ad-en-o-mah). An adenoma of the margin of the lids. BLEPHAROCHROMIDROSIS (blef'-qr-o-kro-mid-ro'-sis). Pigmen- tation of the lids occuring in spots upon the skin. BIvEPHARODOEMA [blef-ar-o-e-de'-mah). A watery swelling of the eye-lids. BLEPHARONCUS ( blef-ar-ong'-kiis). A tumor on the eye-lid. BLEPHAROPHIMOSIS {blef-ar-o-fi-mo'-sis). A congenital con- traction of the palpebral fissure. BLEPHAROPHTHALMIA {blef-ar-off-that'-me-ah). An inflamma- tion of the eye and the eye-lids. BLEPHAROPLAST'Y {blef-ar-o-plas-te). An operation for repair- ing any lesion of the lids by taking a flap from the contiguous parts. BLEPHAROPLEGIA {blef-ar-o-ple'-je-ah). The falling down of the upper lid from paralysis. BLEPHAROPTOSIS ( blef-ar-op-to' -sis ). Ptosis ; a falling of the lid. BLEPHARORRHAPHY {blef-ar-or'-a-fe). The operation of stitch- ing together the upper and lower lids. BLEPHAROSPASM {blef'-ar-o-spazm). A spasmodic contraction of the lids. BLEPHAROSTAT {blef'-ar-o-stat). An eye speculum. BLEPHAROTOMY [blef-ar-ot'-o-me). Cutting of the orbicularis. BLIND SPOT (<^//«^ 5/(7/ ). The papilla. The entrance of the optic nerve. "BLUE STONE" (<^/z^^«y/'c'«^). The sulphate of copper. Formerly much used in the treatment of granular ophthalmia. BRACHYMETROPIA (brak-e-me-iro'-pe-ah). Same as myopia. BUPHTHALMIA {buf-thal'-ine-ah). A marked enlargement of the eye in all of its parts. It is a disease of childhood and is prob- ably glaucomatous. CALIGO {kal-i'-go). Dimness of sight, or blindness, sometimes coming on without apparent cause. CALIGO CORNEA (kal-i'-go kor'-ne-ah). Dimness of sight from opacity of the cornea. CALIGO HUMORUM [kal-i'-go u'-mor-uni). An obscurity of vision arising from a defect in the humors of the eye. CALIGO LENTIS {kal-i'-go len'-tis). An opacity of the crystalline lens. The true cataract. CAMERA [kam'-er-ah). The anterior and posterior chambers of the eye. CANALICULIS {kan-al-ik'-u-lus). A canal for the passage of tears from the lachrymalis to the lachrymal sac. 370 TEXT -BOOK OF OPHTHALMOLOGY. CANAL OF CLOQUET ( kan-al' of Klo-ka ). A channel for the hya- loid artery. CANAL OF SCHLEMM {kanal' of Schlemm). A venous space at the junction of the sclerotic and cornea. CANITIES [kan-ish'-e-ez). Decoloration of the lashes. CANTHOPLASTY [kan'-tho-plas-te). The operation of transplant- ing a portion of the the occular conjunctiva to the external can- thus. Extension of the canthus by any operation. CANTHOTOMY [kan-iJwf-o-me). The operation for enlarging the palpebral fissure. CANTHUS [kan'-thus). The angle formed by the junction of the eye-lids. CAPSULE OF TENON {kap'-sul of Te'-non). A delicate fibrous sheath enveloping the eye-ball and forming the socket in which the globe revolves. CAPSULITIS [kap-su-le'-tis). Inflammation of the capsule (Tenon's) covering the e3^e. CAPSULOTOME (kap'-sii-lo-tom). An instrument for incising the capsule of the crystalline lens. CAPSULOTOMY {kap-su-lot'-o-my). The operation of incising the capsule of the crystalline lens. as in operations for cataract. CARUNCULA ( kar-un'-ku-lah ) lachrymalis. The small red body situated in the inner angle of the eye. CATACLEISIS [kat-ak-li'-sis). A morbid or spasmodic closing of the eye-lids CATAPHORIA ( kat-afo'-re-ah ). A tending of the visual line down- ward. CATARACT {kat-aj^-akt). Obstructed vision caused by opacity of the crystalline lens or its capsule. Capsular c, an opacity upon the capsule of the lens. Lenticular c, an opacity of the lens proper. Senile c, opacity of the lens due to age. Traumatic c, cataract due to injury, CATOPTRICS {kat-op'-triks). That branch of optics which treats of the reflection of light. CATOPTRIC TEST (kat-op-trik test). A test which depends upon the three images seen upon the healthy eye from a light held be- fore it. CENTERING OF LENSES {se7i'-ter-ing of lenz'-es). The adjust- ing of lenses so that the optical centre of the glass is exactly in front of the pupil. CENTRAD {sen' -trad). A prism which will produce a deviation equal to one-hundredth of a radian. CENTRA DIAPHANES {sen'-trah di'-afafies). Cataract caused by obscurity of the central portion of the lens. GLOSSARY. 371 CENTRE OF CURVATURE {scn'-ter of ker'-vat-ur). That point through which rays pass without being reflected. CENTRE OF ROTATION {sen' -ter of ro-ta'-shun). The point about which the eye revolves. CERATOME. A knife for dividing the cornea. CERATOMY. Cutting of the cornea. CHALAZION {kal-a-ze'-on ). A tumor of the lids formed by disten- tion of one of the meibomian glands. CHEMOSIS {ke-mo'-sis). Swelling and oedema of the ocular con- junctiva. CHOKED DISK. A swelled or oedematous condition of the optic disk occurring as a result of increased intra-cranial pressure. CHORIO-CAPILLARIS [ko-re-o-kap-il-a'-ris). The inner of the three vascular layers of the choroid, consisting of a network of capillary vessels. CHOROID { ko'-roid). The posterior segment of the uvea, or middle tunic of the eye. CHOROIDITIS ko-roid-i'-tis). Inflammation of the choroid. CHOROIDO-IRITIS [ko-roid'-o-i-ri'-tis). An inflammation of the choroid and iris. CHOROIDO-RETINITIS ( ko-roid'-o-ret-in-i'-tis). An inflammation of the choroid and retina. CHROMATISM {kro'-mat-izni). The prismatic aberation of the rays of light. CHROMATOGENOUS {kro-mat-of'-en-us). Generating color or pigment. CHROMATOLOGY [kro-mat-ol'-o-ji). The science of colors. CHROMATOPSY {kro'-mat-op-sc). Colored vision. CHROMATROPE {kro'-mah-trop). An instrument for exhibiting a variety of colors, producing, by a rapid revolving motion, beau- tiful pictures. CILIA [sil'-e-ah). The eye-lashes. CILIARY BODY ( sil'-e-a-rc body ). The mid portion of the uvea or pigmentary tunic of the eye; composed of the ciliary muscle and the ciliary processes. CILIARY MUSCLE. The circular muscle of accommodation of the eye. CILIARY NERVES. Long, branches of the nasal which supply the ciliary muscle. Short, nerves from the ciliary ganglion which supply the ciliary body. CILIARY NEURALGIA. Irritation of the ciliary nerves character- ized by pain in and around the eye, over the brow, and down the side of the face. CILIARY^ REGION. Of or pertaining to the ciliary body ; that por- tion of the globe which is concerned in accommodation. 372 TEXT -BOOK OF OPHTHALMOLOGY. CILLOSIS [sil-o'-sis). Spasmodic trembling or agitation of the eye-lids. CIRCLE OF DIFFUSION. The image of the retina formed by a near object when the eye is adjusted for distance. CIRCULUS ARTF:RI0SUS IRIDIS. An artery which encircles the iris. CIRCUMAGENTES {sir-kum-aj'-cn-tez). The oblique muscles of the eye. CIRCUM- CORNEAL ZONE. A pink zone of vessels around the cornea. CIRCUM -LENTAL SPACE. The space between the equator of the lens and the ciliary processes. CIRSOPHTHALMIA [sir'-soff-thal'-me-ah). A varicose condition of the eye. CLAIRVOYANCE \klar-voy-anz). Literally, " clear-sightedness," or " clear vision." COCAINE {ko-kah'-in or ko'-kan). An alkaloid obtained from the leaves of the Erythroxylon cpca. COLLYRIUM {kal-ir'-e-uui). An eye-wash; a medicated applica- tion, usually a lotion for the eyes. COLOBOMA {kol-o-bo'-mah). A gap or fissure, usually congenital, in any part of the eye or the eye-lid. COLOR. The impression wdiich the light reflected from the surface of bodies makes on the organs of vision. COLOR-BLINDNESS. The inability to recognize colors correctly^ COLOR SENSE. The power which the retina has of perceiving color. COMMOTIO RETINA [kom-o'-she-o retina). Oedema of the retina. GONCAVO - CONVEX. Having one face concave, the other convex. CONCOMITANT SQUINT. A form of squint in which one eye, al- though deviated, moves in conjunction with the other, so that the amount of deflection remains the same in all parts of the field of vision. CONICAL CORNEA (keratoconus). A condition of the cornea iu which it bulges forward in the form of a cone. CONJUGATE FOCUS. Any other focus besides the principal focus. CONJUGATE PARALYSIS. Loss of power of motion of the two eyes in some one direction. CONJUNCTIVA [kon-junk-ti'-vah). The mucous membrane lining the eye-lids and eye-ball. CONJUNCTIVITIS [kon-junk-tiv-i'-tis). An inflammation of the conjunctiva. CONUS {konus). The wedged shaped posterior staphyloma found in the fundus of the eye in myopia. Also called the myopic crescent. GLOSSARY. 373 CONVERGENCE. The act of converging or of being directed to- ward a common point. In vision, the direction of the lines of fixation so that both fall upon the point fixed. CONVERGENT STRABISMUS. The turning in of the eye-ball. COPIOPIA [kop-e-o'-pe-ah). Fatigue or weariness of vision. COQUILLES [ko'-kil) ( Fr.) Shelled shaped glasses. CORE. The pupil. CORECLEISIS or COROCLISIS {ko-ro-kli'-sis). Obliteration of the pupil. CORECTOMY {kor-ek'-to-me). The operation for artificial pupil by cutting away part of the iris. CORECTOPIA [kor-ek-to' -pe-ah). An eccentric position of the pupil. COREDIALYSIS {kor-e-di-al'-is-is). A separation of the iris from its attachment. CORELYSIS [kor-el'-is-is). The operation of breaking adhesions between the iris and lens. COREMORPHOSIS {kor-e-mor'-fo-sis). The operation of making an artificial pupil. CORENCLEISIS [kor-en-klV-sis). An operation for artificial pupil. COREOMETER {kor-e-om'-et-er). An apparatus for measuring the width of the pupil. COREONCION ( kor-e-oii'-se-07i). A kind of hook for the operation of artificial pupil. COREPLASTY {kor-e'-plas-te). Operations in general for artificial pupil. CORNEA {kor'-ne-ah). The transparent convexo-conave substance forming the anterior part of the eye-ball. CORNEAL ASTIGMATISM. That condition in which the radii of curvature of the cornea are not equal. CORNEAL LOUPE. A strong, mounted lens, for examination of the cornea by oblique illumination. CORNEAL OPACITY. The scar remaining after a lesion of the cornea. CORNEAL REFLEX. Illumination of the cornea for the purpose of determining the presence of ametropia. CORNEAL ULCER. An ulcer on the surface or in the substance of the cornea. CORNEITIS {kor-7ie-i'-tis). Inflammation of the cornea. CORPUS VITRIUM. The vitreous body. CORRUGATOR SUPERCILII. The muscle that wrinkles the brow. CORTEX OF LENS. The outer part or shell of lens. CORTICAL CATARACT. Opacity of the cortical layers of the lens. COUCHING {kowch'-ing). An old operation for cataract consist- ing in depressing the lens into the bottom of the vitreous. 374 TEXT- BOOK OF OPHTHALMOLOGY. CROSSED DIPLOPIA. A tending of the axis of the eye outward thus projecting the line of the vision across that of the other eye. CROUPOUS OPHTHALMIA. Membranous exudation and soft, painless swelling of the conjunctiva. CRUSTA LACTEA. a moist eczema of the lids of children. CRYPT -OPHTHALMUS. Absence of both eye-lid and conjunc- tival sac. CRYSTALLINE LENS. A transparent, double convex lens, situ- ated in the fore part of the vitreous humor of the eye. CUL-DE-SAC [kul'-de-sak'). The fold of transition between the ocu- lar and palpebral conjunctiva. CL^P. A depression of the optic disk in glaucoma. CYCLITIS [sik-li'-tis). Inflammation of the ciliary body. CYCLOPIA {si-klo'-pe-ah). Fusion of the two orbits in the middle of the face. CYCLOPLEGIA {si-klo-ple'-je-ah). Paralysis of the ciliary muscle. CYCLOTOMY {sik-lot'-o-me). Division of the ciliary muscle; an operation for glaucoma. CYLINDERICAL LENS. A lens made from the segment of a cylinder. CYSTICERCUS [sis-te-ser'-cus). A tailed worm, of the genus en- tozoa, sometimes found in the vitreous. DACRYADENALGIA {dak-re-ad-en-al'-je-ah). Pain in the lach- rymal gland. DACRYADENITIS {dak-re-ad-en-i'-tis). Inflammation of the lach- rymal gland. DACRYOCYST {dak'-re-o-sist). The lachrymal sac. DACRYOCYSTALGIA {dak-re-o-sis-tal'-je-ah). Pain in the lachry- mal sac. DACRYOCYSTITIS ( dak-re-o-sis-ti'-tis). Inflammation of the lach- rymal sac. DACRYO - CYSTO - BLENNORRHCE A. A discharge of mucus from the lachrymal sac. DACRYO - CYSTO - PYORRHOEA. A discharge of pus from the lachrymal sac. DACRYOLITE {dak'-re-o-lit). A calcarious concretion in the lach- rymal passage. DACRYOMA {dak'-re-o-mah). An obstruction in the puncta lacb- rymalis, causing an overflow of tears. DACRYOPEUS {dak-re-o'-pe-us). Causing tears. DACRYOPS {dak' -re-ops). A cyst filled with clear liquid, due to the distention of one of the ducts of the lachrymal gland. DACRYORRHCEA [dak-re-or-e'-ah). A morbid flow of tears. DACRYOSOLEN {dak-re-o-so'-len). The lychrymal canal or duct. GLOSSARY. 375 DACRYOSOIvENITIS (dak-re-o-so-le7i-i'-tis). luflammatiou of the lachrymal duct. DALTONISM {dal'-ton-izm). Colorblindness. DANGER ZONE. The ciliary zone ; that part of the sclerotic over the ciliary body. DARK ROOM. A room darkened for the purpose of examination of eyes by artificial illumination. DASYMA. Roughness on the internal surface of the eye-lid. DATURINE {datezv'reoi). An alkaloid derived from the datura stramonium, which causes dilatation of the pupil. DECENTERED LENSES. Lenses in which the optical centre is not before the pupil. DENDRIFORM {dend'ri-form) ULCERS. Dendriform keratitis; a kind of ulcer of the cornea, which has branch-like ramifications. DEPLUMATION {dep'hi-nia-shun). A term applied to a disease of the eye-lids, in which the eye-lashes fall off. DEPRESSIO CATARACTS {de-presh'e-oh kat-a-rak'ti). Artificial luxation of the lens The oldest operation for cataract. DEPRIMENS OCULI {de-pri'mens ok'u-li). A name given to the rectus inferior, from the action of this muscle in drawing down the eye-ball. DESCEMETITIS (des'e-me-ii'tis). Inflammation of the membrane of Descemet. DESCEMETOCELE {des'e-me'to-seel). A waterj^ tumor of Desce- met's membrane. DESCEMET'S {des-e-mayz) MEMBRANE. The structureless, trans- parent membrane lining the posterior surface of the cornea. DIABETIC {di-a-bet'lk) CATARACT. Cataract due to diabetes mellitus. DILATOR PUPILL.^ {di-lay'tur pew'pil-i). The radiating fibres of the iris. DIOPTOMETRY {di-op-tom'e-try). The determination of the re- fraction and accommodation of the eye. DIOPTRE {di-op'tur). The unit used in measuring glasses and the refractive states of the eye. DIOPTRIC [di-op'trik) APPARATUS OF THE EYE. The cor- nea, aqueous humor, cr3'Stalline lens, and vitreous humor. DIPHTHERITIC OPHTHALMIA {dif-tftur-it'ik of -thai' me -ah). A conjunctivitis produced by diphtheria. It is characterized by a hard, painful swelling of the lids, a scanty sero - purulent or saneous discharge, etc. DIPHTHERITIC PARALYSIS. A paralysis of accommodation sometimes following diphtheria. DIPLOPIA {di-ploh'pce-ah). Double vision. The condition iq which an object seen appears double. 376 TEXT -BOOK OF OPHTHALMOLOGY. DIRECT IMAGE. The image as seen with the ophthalmoscope by the direct method. DIvSC (dis/:) OPTIC. The entrance of the optic nerve. DISCISSION {(iis-sizh'un). The needle operation for cataract. DISPERSING LENS. A concave lens. DISSEMINATED CHOROIDITIS. An inflammation of the choroid in which the exudate is scattered generally over the fundus. DISTICHIASIS {dis-tik'e-a'-sis). A condition in which there are two rows of cilia, one or both of which are turned inward to- ward the eye-ball. DIVERGENCE. An outward deviation of the visual lines. The amount, normal or abnormal, which the eyes can roll outward from the position of fixation. DIVERGENT SQUINT. Strabismus in which the eye turns out. DOLICHOCEPHALY {dol'i-ko-sef-aly). A prominence of the bones of the face and orbit. DUBOISIA {dew-boy' she-ah). The active principle of the duboisia m^oporoides. DUCTUS LACHRYMALIS {dukt'us lak'ri-mal'iis). The duct leading from the lachrymal sac to the nasal fossa. DYNAMIC {di-nam'ik) REFRACTION. The act of accommodation. DYSCHROMATOPSIA {dis-kr oh' ma-top' see-ah). Difficulty in dis- tinguishing colors. DYSCORIA {dis-ko're-ah). Non-circular form of the pupil. DYSLEXIA. Hysterical asthenopia. DYSOPSIA [dis-op'se-ah). Painful vision. DYSOPSIA LATERALIS. An aff"ectiou in which an object can only be seen when seen obliquely. ECARTEURS {a-kar'-tuzc). An instrument for separating the lids- ECHINOPHTHALMIA {e-kin-of-thal'-me-ah). A form of ophthal- mia in which the lashes project like the quills on a hedgehog. ECTOPIA {ek-toh'pe-ah) OF LENS. A term applied to any case where the lens is out of its place. A dislocation of the lens, either congenital or traumatic. ECTROPION {ek-troh'-pe-an). A turning out or eversion of the eye-lids. Same as Ectropium. EGYPTIAN OPHTHALMIA. An acute form of ophthalmia, at- tended with a purulent secretion. Also called Military Oph- thalmia. EMMETROPE. Is one, whose eyes, when their accommodation is relaxed, are accurately adjusted for parallel rays. EMMETROPIA {em'-e-troh'-pe-ah). The condition of the eye in which parallel rays will focus upon the retina without accom- modation. ENCANTHIS. A small red excrescence on the caruncula lachrymalis and the semilunar fold of the conjunctiva. GLOvSSARY. 377 ENCANTHIS BENIGNA. Benign new growths of the caruncle. ENCANTHIS MALIGNA. Malignant new growths of the caruncle. ENOPHTHALMUvS {en'-of-thaVmus). A condition in which the eye is unusually deep in its socket. A retraction of the eye- ball. ENTROPION {en-iroh'-pi-im). That condition in which the eye- lash and eyelid are turned in towards the eye. Same as En- tropium. ENUCLEATION [c-new'-kle-a'shu7i). The removal of the eye. EPHIDROSIS {ef'-e-ch^oh'sis). An excessive secretion of the sud- oriferous glands of the upper lid. EPICANTHUS {ep'-e-kan'thus). A condition in which a fold of skin projects over and hides the inner canthus of the eye. EPILATION {ep'e-lay-shun). The removing of the cilia by plucking ing them out by the roots. EPIPHORA {e-pif'-ur-ah) A condition in which the tears run over the lids instead of through the natural passage, due usually to stricture of the lachrymal passage. EPISCLERITIS {skle-ry'-tis, skle-re'-tis). An inflammation of the ocular sub-conjunctival connective tissue. ERROR OF R3FRACTI0N Any deviation in the normal refrac- tion of the eye. Ametropic. ERYTHROPSIA [er'-e-throp'-see-ah). Red vision. ESERINE {es'-ur-een ). An alkaloid obtained from the calabar-bean, used as a myotic. ESOPHORIA [es'-oh-foh'-re-ah). A tendency of the visual lines in- ward; an excessive convergence of the internal recti, owing to insufficiency of the externi. ESOTROPIA [es' -oh-troh' -pe-ah ). A manifest turning inward of the eyes ; an inward or convergent squint. EVISCERATION {e-vis'-ur-a-shun). The operation of removing the contents of the globe, the sclerotic being retained. EXCLUSION OF PUPIL. The condition caused by the iris being bound down to the capsule of the lens. EXENTERATION {eks-en' -Uir-a-shun) The same as Evisceration. EXOPHORIA {eks'-o-foh'-re-ah). A tendency of the eyes to deviate outward, so that they diverge from the point of fixation. Also termed insufficiency of the interni. EXOPHTHALMIC [of-thal'-mik). Pertaining to exophthalmus; as exophthalmic goitre. EXOPHTHALMIC GOITRE {goy'-tur). A disease, one of the sym- toms of which is protusion of the eye-balls. EXOPHTHALMOMETER imom'-e-ter). An instrument for meas- uring the degree of exophthalmus. EXOPHTHALMOS [of-thal'-mos). A condition in which the eye protudes abnormally from the socket, no matter what the cause. 378 TEXT -BOOK OF OPHTHALMOLOGY. EXTERNAL RECTUS. The muscle that turns the eye-ball out- ward. EXTRLVSIC MUSCLES. The muscles outside the globe. EYE. The organ of vision. EYEBROW. The fold of skin, lined with hairs, situated at the upper margin of the orbit. EYELASH. The delicate hairs projecting from the edges of the eyelids. EYELID. The projecting folds from above and below which cover the eye. EYE -SPECULUM. An instrument for keeping the lids apart dur- ing an operation. EYE WATER. A medicated eye wash. FALSE IMAGE. The image formed by the squinting eye. FAR -POINT. The farthest point at which, with full relaxation of accommodation, objects can be seen distinctly. FAR SIGHTEDNESS. A defect of vision, by which objects cannot be seen perfectly, owing to the visual axis being too short, or to the hardening of the crystalline lens consequent to age. FIBRES OF MULIvER {miiel'ler). Fibres of connective tissue which run perpendicularly through the retina. FIELD OF VISION (VISUAL FIELD). The portion of space containing all the points that are visible to the eye, remaining fixed in one position. FIFTH NERVE (THE TRIGEMINUS). The nerve supplying sensation to the face and mobility to the muscles of mastica- tion. The ophthalmic nerve is derived from this. FILARIA {fy-lay'7'e-ah). A thread like parasitic worm which in- fests the cornea of the eye, particularly that of the horse. FIXATION FORCEPS. Small forceps for steadying the eye in operations. FLOCCI VOLITANTES {flok'si vol'-i-tan'tez). The imaginary objects floating before the eyes in cases of depraved sight. See Muscae Volitantes. FLUORESCEIN [flew' o- res' e-i7i). A coal-tar derivative which colors green those portions of the cornea which have been de- prived of epithelium. FOCAL ILLUMINATION. Examination of the eye with light focused upon it by a strong lens. FOCAL INTERVAL. The interval between the focus of the merid- ian of greatest curvature and the focus of the meridian of least curvature of an irregular refracting surface. FOCUS. The point at which rays meet after passing through a convex lens. FOLD, SEMILUNAR. A crescentric fold of the conjunctiva at the inner canthus. GLOSSARY. 379 FOLLICULAR (fo-lik'yu-lur) OPHTHALMIA. A form of con- junctivitis characterized by small pinkish prominences on the conjunctiva. FONTAXA'S {/on-tah'uah) SPACES. The open spaces of the meshwork of the ligamentum pectinatum. FORAMEN {/o- ray' men) SUPRA-ORBITAL. The supra - orbital hole or notch foi the passage of the superciliary artery, vein and nerve. FOREIGN BODY. Any foreign substance within the lids or within the globe. FORNIX. The conjunctival cul-de-sac. FOSSA LACHRYMALIS. A depression in the frontal bone for the reception of the lachrymal gland, FOSSA PATELLARIS [pa'tel-la'ris). The depression in the front part of the vitreous for the lens. FOVEA {foh've-ah ) CENTRALIS. A small depression in the mac- ula lutea. FRANKLIN GLASSES. Same as bifocals. FULMINATING GLAUCOMA. The most malignant type of glau- coma. FUNDUS OCULL The back part of the eyeball or the portion cov- ered by the retina. FUSION POWER. The power of the ocular muscles to make the two images fuse. GERONTOXON {je^^'-on-toks'-on). A whitish ring occuring in old people in the cornea, near, and concentric with its margin. Called arcus senilis. It is due to a deposition of colloid materiaL GLASSES. Lenses made of glass to aid in vision. GLAUCOMA {glaw-ko'-mah). An increase of intra-ocular pres- sure, producing hardness of the eye-ball, and rapidly failing vision, due to injury of the retina inflicted by pressure upon it. GLAUCOMATOUS {glaw-ko'-ma-tus) RING. The yellowish halo seen around the excavated nerve head in glaucoma. GLIOMA {gly-oh'-mah) RETINAE. A round cell sarcoma of the retina, occurring in young people. GLOBE. The eyeball. GOGGLES. Colored glasses with wire or silk sides to protect the eyes. GONORRHCEAL {gon'-ur-e'-al) OPHTHALMIA. An acute puru- lent ophthalmia caused by an infection from a gonorrhoeal dis- charge. GONORRHCEAL IRITIS. A plastic iritis, said by some, to be due to gonorrhea. GRANULAR LIDS. A granulated condition of the eyelids ; known also, as trachoma. 380 TEXT -BOOK OF OPHTHALMOLOGY. GRAVES DISEASE. A disease which is characterized by an ab- normal protuberance of the eyeballs. GREEN. The fourth color in the spectrum. GYMNASTIC PRISMS. Prisms placed before the eyes for the pur- pose of strengthening the muscles of the eyes by exercise. HAEMALOPIA {he'-niul-o'-pe-ah). A disease of the eye in which every object appears of a blood color. HAEMOPHTHALMIA [he'-mof-thal'-vic-ah). An effusion of blood into the eye. HAEMOPHTHALMUS. Same as haemophthalmia. HALO VISION. A condition in which a light or colored ring ap- pears to encircle anything, especially a flame. HARD CATARACT. A cataract having a hard nucleus. HARLAN'S TEST. A test to detect malingerers. HASNER'S VALVE. A fold in the nasal duct at its lower orifice HEBETUDO VISUS. Asthenopia. HELOSIS. The eversion or turning out of the lids ; also applied to convulsions of the muscles of the eye. HEMERALOPIA [hem'-ur -a- loh'- pe-ah). A defect of vision by which objects are seen only in broad daylight; day-sight; night- blindness. It is also applied to a disorder of vision in which objects cannot be seen well, or without pain, by daylight. HEMIACHROMATOPSIA {a-kr oh' -ma-top' -se-ah). Obliteration of the color sense in one-half of the visual field. HEMIANOPSIA {hemi'-an-op' -se-ah). Obscuration of one-half of the visual field. HEMIOPALGIA {hemi'-o-pal' -ge-ah). Hemicrauic pain of the eye. HEMIOPIA {oh'-pe-ah) OR HEMIOPSIS. Disordered vision in which a patient sees only the half of an object. HEN - BLINDNESS. Inability to see except by daylight ; so termed because hens are said to be subject to it. HENLE'S {hen'-leez) GLANDS. Tubular glands in the conjunctiva. HERPES {hur'-peez) CORNEAE. A vesicular eruption on the cornea. HETERONYMOUS ( het' -ur-on-i-imis ) DIPLOPIA. Same as crossed diplopia. In which the image of the left eye is on the right side, in which case the visual axes are divergent. HETEROPHORIA {/o'-re-ah). A condition in which one of the visual axes tends to deviate from the point of fixation. HETEROPHTHALMUS. The condition in which the color of one iris is different from the other. ..HIPPUS. A pathological condition which consists in a constant and rapid change in the diameter of the pupil. .HOLMGRENS TESTS. A set of colored skeins for the detection of color blindness. GLOSSARY. 381 HOMATROPINE {Iwh-mat'ro -pcen). An alkaloid derived from atropine and used as a mydriatic. HOMER'S MUSCLE. Fibres of the ligamentum canthi internum which are inserted in the inner wall of the orbit. HOMOCENTRIC {hoh' mo-sen' trik) RAYS. Rays which all either intersect at the same point or are parallel (i. e., intersect at infinity). HOMONYINIOUS DIPLOPIA {hoh-mon'i-nms di-ploh' pe-ah) A de- viation of the axis of vision inward, thus projecting the image outward. HORDEOLUM {hawr-dee'o-lum). A small furuncle in the margin of the lid. HORIZONTAL MERIDIAN. A line drawn around the globe of the eye at right angles to the vertical diameter. HORN OF THE EYELID. A cutaneous growth on the eyelid. HOROPTER {ho-rop'tiir). A line or surface in the field of vision, of such a shape that each point of it throws images upon corre- sponding points of the retinfe of the two eyes, and is hence seen as one point by both. It varies in character with the position of the eyes. HYALITIS {hy'a-ly'tis). Inflammation of the vitreous humor. HYALODECRYSIS {hy'a-lo-dek'rih-sis). Escape of part of the vitreous humor of the eye. HYALODEOMALACIA {hy' a-lo' de-o-may-lay' sih-ah). Softening of the vitreous. HYALOID ARTERY. An artery that traverses the vitreous antero- posteriorly in fcetal life. HYALOIDITIS {dey'tis or dee'tis). Inflammation of the hyaloid membrane. HYALOID MEMBRANE. The extremely delicate membrane which contains the vitreous humor. HYDROPHTHALMUS [hy-drof-thal'mtis). An enlargement of the eye in all directions. HYOSCINE {hy'o-seen). An alkaloid derived from Hyoscyamus Niger. HYOSCYAMINE {hy'o-sy'a-meen). An alkaloid derived from Hyo- scyamus Niger; more soluble than Hyoscine; used as a mydriatic. HYPHEMIA {hip-e'me-ah). A collection of blood in the anterior chamber. HYPERBOLIC LENSES. Lenses for correcting the error of con- ical cornea. HYPERESOPHORIA [es'oh-foh'ree-ah). A tendency of the visual lines upward and inward. HYPEREXOPHORIA {ek'soh-foh'ree-ah). A tending of the visual lines upward and outward. 382 TEXT -BOOK OF OPHTHALMOLOGY. HYPHRMETROPIA. That condition of the eye in which, when the accommodation is relaxed, the rays are brought to a focus be- hind the retina. HYPEROPIA {hy' piir-oh' pee-ah ). The same as hypermetropia. HYPP:R0PES {/ly'pur-ope). Those persons who are affected with hyperopia. HYPEROPSLA {hy'piir-op'sc-ah). Extremely acute vision. HYPERPHORIA [foh're-ali). A tending of one visual line in a direction above its fellow. HYPERTONIA {toh'ne-ah). Excessive intraocular tension of the globe. HYPOCHYMA {hy-pok'e-niah ). An old name for cataract. HYPOGALA {hyp'og-a-lah). The effusion of a milk-like fluid into the chambers of the eye. HYPOMETROPIA {hy'po-me-tro'pe-ah). A scientific name for the condition usuall}^ known as m}Opia. HYPOPYON {hy-poh'pe-un). A collection of pus in the anterior chamber. HYPOSPHAGMA {hypos-fag'mah). Subconjunctival hemorrhage. HYPOTONIA {toh'ne-ah). Diminished tension of the globe. HYSTERICAL ASTHENOPIA. Weakness of vision often occur- ring in hysterical patients. ICE -BLINDNESS. A disease of the eyes caused by the brilliant reflection of the sun from the ice. IDIOPATHIC {id'e-oh-path'ik) IRITIS. A form of iritis in which no local injury or constitutional disease can be accredited to its origin. IDIOPATHIC RETINITIS. Retinitis occurring without known cause. ILLACRYMATIO [il-lak'-re-via'-she-o). Excessive involuntary weeping : sometimes synonomous with Epiphora. ILLAQUEATION {il-lak'we-a'shun). An old operation for chang- ing the position of an eye-lash by encircling its base in a loop made by a thread passed through the tissues. IMAGE. The spectrum or picture of an object formed by the re- flection or refraction of rays of light from its various points. INCARCERATION {in-kahr'-sur-a-shini) OF THE IRIS. A con- dition in which a portion of the iris becomes adherent to a cor- neal scar. INCIDENT RAY. The name given to a ray of light before its pas- sage into the second medium. INCIPIENT {in-sip'-e-ent) CATARACT. The first stage of cataract. INDEX OF REFRACTION. The refractive power of any substance compared with that of water. INFERIOR OBLIQUE (ob-/ike\ ob-leek') MUSCLE. The ocular muscle that rotates the cornea upward and outward. GLOSvS.^RY. 383 INFERIOR RECTUS MUSCLE. The ocular muscle that rotates the globe downward. INSUFFICIENCY OF THE OCULAR MUSCLES. Weakness of the muscles of one or both eyes, causing inability to move the globe so as to secure binocular vision. INTERMITTENT STRABISMUS {stra-biz-mus). Strabismus which appears and disappears suddenly. INTERNAL RECTUS MUSCLE. An ocular muscle, the function of which is to rotate the globe inward. INTERPALPEBRAL SPOT. The triangular yellowish patch bord- ering the cornea on either side in old people ; due to hyper- trophy and colloid infdtration of the conjunctiva as a result of irritation arising from dust, etc. Same as pinguecula. INTERPUPILLARY DISTANCE. The distance between the centres of the pupils. INTERSTITIAL KERATITIS [ker'-a-ty'-tis, tee'-tis). A diffuse in- flammation of the whole thickness of the cornea. INTRA - OCULAR TENSION. A term used to designate the degree of pressure of the fluids of the eye. IRALGL\ {i-ral'-gih-ah). Pain of the iris. IRIANKISTRIUM {ir-ih-an-kis' -trih-um) or IRIANKISTRON. A hook-shaped instrument used in the operation for artificial pupil by separation. IRIDAEMIA {ir-ih-de'-rne-ah). Hemorrhage from the iris. IRIDALGIA [ir-id-al'-jah). Pain of the iris. Iralgia. IRIDAUXESIS {ir'-i-doh-e^-sis). Thickening or growth of the iris by the exudation of fibrin into its substance. IRIDECTOMUS {ir'-i-dek'-to-mus). A kind of knife used for iri- dectomy. IRIDECTOMY {ir'-i-dek'-to-mee). The operation of removing or cutting out a portion of the iris. IRIDECTROPIUM. Eversion of a portion of the iris. IRIDENTROPIUM. Inversion of a portion of the iris. IRIDENCLEISIS. An operation for displacing the pupil from its natural position, effected by drawing the iris into a wound made near the periphery of the cornea and causing it to become ad- herent there. IRIDEREMIA [ee-ree'-mee-ah). Defect or imperfect condition of the iris. IRIDES. Plural of iris. IRIDESCENT VISION. The condition in which variously hued borders surround artificial lights. IRIDESIS {i-rid'e-sis). Strangulation of a part of the iris to form an artificial pupil, IRIDO - AVULSION {ir'-i-doh-a-vul'-shun). A term applied to the total removal of the iris by tearing it away from its periphery. 384 TEXT -BOOK OF OPHTHALMOLOGY. IRIDOCELE {seel). Hernia of the iris. IRIDO- CHOROIDITIS {koh'-ree-oy-dy'-tis, dee'-tis). Inflammation of the iris and choroid coat of the eye. IRIDOCINESIS {ir'-i-doh-sih-ne'-sis). The movement of the iris, its contraction and expansion. IRIDOCYCLITIS {ir'-i-doh-si-kli'-tis). Inflammation of the iris and ciliary body. IRIDODIALYSIS {ir'-i-doh-di-al'-i-sis). The operation for artificial pupil by separation. IRIDODONESIS {ir'-i-doh-nee'-sis). Trembling of the iris. IRIDOMALACIA {ir'-i-doh-ma-la'-she-a). Softening of the iris. IRIDONCUS {h-'-i-don'-kus). Tumor or swelling of the iris. IRIDOPERIPHACITIS {pur'-i-fa-si'-Hs). Inflammation of the cap- sule of the lens of the eye. IRIDOPLANIA. Trembling of the iris ; iridodonesis. IRIDOPLEGIA {plee'-jah). Paralysis of the iris. IRIDORHEXIS. Tearing away of the margin of the iris. IRIDORRHAGAS {dor'-rha-gas) Fissure of the iris. IRIDOTOMY [dot'-o-mee). The operation for artificial pupil by in- cision. IRIDOTROMUS {dot'-ro-mus). Trembling of the iris. IRIS {ey'ris). The pigmented membrane separating the anterior and posterior chambers of the eye. It is pierced by a central circular hole (the pupil). It consists of the circular muscular fibres (sphincter of the iris) by which the pupil is contracted, of radiating elastic fibres by which the pupil is dilated, and of a posterior pigment layer which really belongs to the retina. The iris is attached to the sclero-cornea by the ligamentum pec- tinatum. IRITICUS. Iritic; belonging to iritis. IRITIS [ey'-ri-tis, ree'-tis). Inflammation of the iris. IROTOMY. The same as iridotomy. IRREGULAR ASTIGMATISM. The condition when the refraction of the eye no longer presents any uniformity. ISCHAEMIA {is-ke'-me-ah) RETINAE. Diminution of arteries in the retina. ISCHURIOPHTHALMIA {is-kew'-ry). Ophthalmia resulting from the suppression of urine. ISOMETROPIA {ey'-so-me-tro-pc'-ah). The state in which both eyes are alike in their refraction. JABORANDI [jab'ur-an'dce). The Pilocarpus pennatifolius, a South American shrub of the Rutacese. The leaflets produce marked sweating, salivation, increase of the milk and other secretions, miosis and spasm of the accommodation, lowering of the blood pressure and temperature and often marked prostration. These GLOSSARY. 385 effects are due to the presence of an alkaloid, pilocarpine. They also contain the alkaloid, jaborine, which acts like atropine. J. and pilocarpine are used as diaphoretics in detachment of the retina; as a miotic and to reduce the intra-ocular tension in glaucoma, staphyloma and certain ulcers of the cornea. JEQUIRITY {je-kwir'i-tee). An Indian plant, the infusion of which is sometimes used as a remedy against chronic granular ophthal- mia. It is very irritating to the eyes and should not be used. KERATALGIA {ker'at-al'jah). Neuralgic pain of the cornea. KERATITIS {ker'a-ty'tis, tee'tis). Inflammation of the cornea. KERATITIS BULLOSA ( bul-o'sah ). A disease in which small blebs form on the cornea. KERATOCELE {ker'a-toh-seel). Hernia of the cornea. KERATOCONUS (/fe^>^'«?^5). Conical cornea. KERATOGLOBUS {tog' lo -bus). A globular protrusion of the cornea. KERATOHELCOSIS {hel-koh'sis). Ulceration of the cornea. KERATO-IRITIS. Inflammation of both cornea and iris. KERATOKINESIS {ky-ne'sis). The formation of new cells in the cornea. KERATOMALACIA {ma-lay' shah). A purulent infiltration of the whole cornea. It is very destructive. KERATOMETER {tom'ut-ter). An instrument for measuring the cornea. KERATONYXIS {nik'sis). An operation for cataract m which the lens is depressed by a needle passed through the cornea. Para- centesis or any puncture of the cornea. KERATOPLASTIC. Belonging to keratoplasty. KERATOPLASTY {ker'a-to-plas'tee). The repair by operation of defects or redundancies of the cornea; especially, the substitu- tion by operation of transparent for opaque cornea. KERATOSCOPE {ker'a-toh-skope). An instrument for examining the cornea; especially, one for determining from inspection of the cornea the form and curvature of the latter. KERATOSCOPY {ker'a-tos'ko-pee). Examination of the cornea with a keratoscope. Skiascopy. KERATOTOME {ker' a-to-tome) or KERATOME. A knife for in- cising the cornea, KE:RECT0MY {ker-ek'to-me). The operation for obtaining a clear space in an opaque cornea. KOPIOPIA or COPIOPIA {kop'ee-oh'pee-ah). Asthenopia. KORECTOMIA or CORECTOMIA {ko'rek-to'mee-ah). The oper- ation for artificial pupil by removal of a part of the iris. KOROSCOPY {ko-ros'ko-pee). A method of determining the re- fractive state of the eye by examining the movement of light 386 TEXT -BOOK OF OPHTHALMOLOGY. and shadow across the pupil when the retina is illuminated by light thrown into the eye from a moving mirror. KRAUSE'S {krow'zez) GLANDS. Mucous glands in the fornix conjunctiva?. IvACHRYMAL {lak'-ri-mul). Of or pertaining to tears. LACHRYMAL ABSCESS. An abscess of the lachrymal sac. LACHRYMAL APPARATUS. Consists of the lachrymal gland, lachrymal ducts, canaliculi, sac and nasal ducts. LYCHRYMAL GLAND. The gland situated at the upper and outer angle of the orbit. This gland secretes the tears. LACHRYMATION {lak' -ri-7nay' -shun). An increased flow of tears. LACUNAR ORBITAE ( la-kew'-nur or'-bit-a). The roof of the orbit of the eye. LAGOPHTHALMUS {lag'-of-thal'-miis). Complete absence of the eyelids. LAMINA CRIBROSA. A fine web of fibrous tissue on the posterior surface of the sclera for the passage of the optic nerve. LAMINA FUSCA. The external layer of the choroid. LAPIS {lay' -pis) DIVINUS. An application for follicular granula- tions, made of equal parts of sulphate of copper, nitrate of potash, and alum, fused together and moulded. LATENT HYPEROPIA. That part of the hyperopia which the crys- talline lens can overcome. LEAD OPACITY. A corneal opacity caused by the precipitation of lead salts from washes containing lead. LENS. A glass which, owing to its peculiar form, causes the rays of " light to converge to a focus or disperses them according to the laws of refraction. Crystalline 1. A transparent, double convex lens situated be- tween the aqueous and vitreous humors of the eye. Convex 1. A lens which converges the rays of light. Concave 1. A lens which disperses the rays of light. Cylindrical 1. A lens formed from the segment of a cylinder, and may be either convex or concave. Compoiuid 1. A lens consisting of several lenses put together. LENTICONUS {len' -tee-koh' -nus). A transparent conical projection from the posterior surface of the lens. LENTICULAR {len-tik' -yu-lur) FOSSA. The depression in the an- terior part of the vitreous for the lens. LENTICULAR GANGLION. A small reddish body near the back part of the orbit between the optic nerve and the external rec- tus muscle. LEPROPHTHALMIA {lep'-rof-thal-me-ah). Leprous ophthalmia. LEPTOTHRIX {lep'-to-thriks). A mass of fungus in one of the canaliculi. LEUCOMA {ICiV-ko'-mah). Opaque cicatricial tissue in the cornea. GLOSSARY. 387 LEVATOR PALPEBRAE MUSCLE. The muscle which raises the upper lid. IvIDS. The anterior protective coverings of the eye. LiGAMENTUM PECTINATUM {pck'-ti-na'-tum). That part of Descemet's membrane which is reflected on the iris. LIGHT. Light is that great force of nature by the action of which objects are made visible. LIGHT SENSE. The power possessed by the retina of appreciating variations in the intensity of the source of illumination. LIMBUS CORNEAE. The edge of the cornea. LINE OF FIXATION. The line which connects the object looked at, with the center of rotation of the eye. IvINE OF VISION. The line which connects the object looked at with the fovea centralis. LIPPITUDO {lip'-pee-tew-doh). The appearance caused by the ex- posure of the marginal conjunctiva together with the loss of the cilia. LIQUOR MORGx\GNI. A small quantity of fluid between the lens and its capsule. IvOIMOPHTHALMIA. Contagious ophthalmia. LONG SIGHTEDNESS. Presbyopia LOUCHETTES. A kind of opaque glasses in which for each eye there is a small hole, which makes it impossible to look in any other way than through this opening. IvOXOPATHALMUS [lok-sop'-thal-fuus). Having oblique or squint- ing eyes. LUXATION {luk-sah'-shun) OF LENS. Dislocation of the crystal- line lens. MACROPSIA. An affection of the eye in which objects appear larger than they really are. MACULA LUTE A [mak'-yu-lah lew'-te-ah). The yellow spot; a depressed elliptical or circular spot at the centre of the retina; the point of the most acute vision. It contains a central depres- sion, the fovea centralis. MADAROSIS [mad'-ur-oh'-sis). The condition in which the lashes are permanently destroyed. MALINGERING. Pretending blindness to escape irksome duty or to excite sympathy. MANIFEST HYPEROPIA. The hyperopia remaining after the crystalline lens has exerted all of its power. MARGINAL KERATITIS. A form of keratitis characterized by the development of numerous phlyctenules around the rim of the cornea. MARMARYGAE [mar-mar' -ig-e). The appearance of sparks or coruscations before the eyes. 388 TEXT -BOOK OF OPHTHALMOLOGY. MEGALOPSIA {meg' -a-lohp' -se-ah). An affection of the eye in which objects appear larger than they really are. MEGOPHTHALMUS [of-thal'-mus). A condition in which the whole eye is abnormally large. MEIBOMLAN {mey-boh'-mec-un) GLANDS. Small glands between the conjunctiva and the tarsal cartilages. When acutely in- flamed they produce a Meibomian sty ( Hordeolum meibo- mian um) ; when enlarged by obstruction of the duct and thick- ening of the walls they form a chalazion. MEL ANOPHTHALMIA {mel'-an). A melanotic tumor of the eye; it is characterized by the deposition of black pigment. MELANOSIS SCLERAE. Congenital pigmentation of the sclera. MEMBRANA LIMITANS INTERNA. The internal layer of the retina. MEMBRANA NICTITANS. A thin membrane forming a third eye- lid in certain kinds of birds. MEMBRANA PUPILLARIS. A membrane covering the pupil in foetal life. This sometimes fails to disappear. MEMBRANOUS OPHTHALMIA. Same as diphtheritic ophthalmia. MENISCUS GLASSES. Glasses that refract at some distance from the centre, the same as at the centre, so that persons can see obliquely through them. MEROPIA {me-roh'-pe-ah). Partial dulness or obscuration of sight. METAMORPHOPSIA {maivr-fop'-see-ah). An affection of the eyes in which objects appear changed from their natural form. METRE ANGLE. The angle through which the visual line must move upon parallelism to fix an object one metre distant. METRE LENS. A lens, the focal length of which is one metre. MICROPHTHALMIA {mey'-krof-thal'-mee-ah). A morbid shrink- ing or wasting of the eyeball. MICROPSIA {mey-krop'-see-ah). An affection of the eye in which objects appear smaller than they really are. MILITARY OPHTHALMIA. A purulent contagious ophthalmia, same as Egyptian ophthalmia. MILIUM. A small elevation filled with sebum on the skin of the eyelid. MITIGATED STICK. Nitrate of silver, one part, and nitrate of pot- ash, two parts, fused together and moulded into sticks. MOLLUSCUM CONTAGIOSUM. A disease of the sebaceous glands, characterized by the appearance of rounded papules, about the size of a pea and of waxy color. MONOBLEPSIS. A state of vision in which objects are distinct only when viewed with one eye. MOON-BLINDNESS. Functional night blindness. GLOSSARY. 389 MORGAGNIAN [mawr-gan'-yun) CATARACT. A type of cataract ill which the cortical matter has liquefied and the nucleus has been displaced. MUCOCELE [meiv'ko-seel). A distention of the lachrymal sac with clear or turbid mucus MUSCAE VOLITANTES {mus'ec vol'i-tan'teez). Black specks seen floating in the field of vision. A sympton due to opacities in the media, especially in the vitreous humor. MUSCARINE {mus'kur-een). An alkaloid obtained from the al- bumen of hens' eggs. It acts as a ni3'otic and causes contractio-n of the ciliar}^ muscle. MUSCI^LAR ASTHENOPIA. Weakness of the ocular muscles. MYCOPTHALMIA [mey' kof-thal'mee-ah). Fungous inflammation of the eye. MYDRIASIS [mid'rey'a-sis). Dilatation of the pupil. MYDRIATICS [mid'ree-at-iks). Drugs that cause dilatation of the pupil. MYOCEPHALON {mey'oh-seph'a-lon). A knuckle of iris protrud- ing into a corneal ulcer. MYODESOPSIA ( mey' oh-de-sop' see-ah ). Same as muscae volitantes. MYOPIA {mey-oh'pee-ah). The condition of the refraction when the retina is behind the focus. MYOPIC CRESCENT {mey-op'ik kres'ent). A crescent shaped atrophy of the choroid at the posterior pole of the eye. MYOSIS [mey-oh'sis). Contraction of the pupil. MYOTICS [mey-ot'iks). Drugs that cause contraction of the pupil. NASAL DUCT. That part of the tear duct below the lachrymal sac, and opening into the nose. NEAR POINT. The nearest point at which the eye still has maxi- mum visual acuity. NEAR SIGHTEDNESS. Myopia. NEBULA CORNEAE ( neb'yii-lah kawr'nee-ah). A superficial cloudy condition of the cornea from loss of the epithelium. •NECROSIS CORNEAE. A disease characterized by dryness of the conjunctiva, and destructive ulceration of the cornea. NEPHRITIC {nee-frit'ik) RETINITIS. A form of inflammation of the retina associated with Bright's disease of the kidneys. NEURODEALGIA. Pain or excessive sensibility of the retina. NEURODE ATROPHIA. Atrophy of the retina. NEURO - PARALYTIC KERATITIS. An anaesthetic condition of the cornea coupled with ulcerative inflammation. NEURO - RETINITIS. Inflammation of the optic nerve and retina. NICTITATION. Involuntary' convulsive twitching of the eyelids, NIGHT-BLINDNESS. Hemeralopia. NIPHABLEPSIA [nif-ah-blep'se-ah). Blindness caused by the glar- ing reflection of sunlight upon the snow. 390 TEXT -BOOK OF OPHTHALMOLOGY. ♦ NIPHOTYPHLOTES {nif-o-tif-lo'tez). Same as niphablepsia. NITRATE OF SHAVER. A drug, the solution of which is often used in purulent ophthalmias and as a stimulant application in chronic trachoma. NODAL POINTS. These are two points in a lens, the incident ray being directed toward the first and the refracted ray toward the second. The optical centre lies between them. NUCLEAR [new'klee-ur] CATARACT. A form of cataract in which the nucleus of the lens is opaque. NYCTALOPIA [nik'ta-Ioh'pee-ah). Day-blindness. NYCTOTYPHLOSIS [nik'to-tcy-flo'sis). A term for night-blindness. NYSTAGMUS [nis-tag'mus). A term applied to a condition char- acterized by an involuntary', rapid movement of the eyeballs, either from side to side, vertically, or in a rotary direction. OBFUSCATION {ob'fus-ka'shun). Obscure sight. A clouding; as O. of the cornea. OCCLUSION {ok-klew' zhtm) OF THE PUPIL. Blocking up of the pupil by a membrane. OCULAR. Belonging to the eye. OCULAR CONE. A cone formed in the eye by the rays of light, the base being on the cornea, and the apex on the retina. OCULAR SPECTRES. Imaginary objects floating before the eyes. OCULI {ok'yu-ley). Plural of oculus. OCULIST [ok'yu-list). One skilled in diseases of the eye. OCULOMOTOR ( ok' yu-loh-moh' tur) . Of or pertaining to the move- ment of the eye ; as the O. nerve ( oculomotorius ) the third cerebral nerve which innervates all the muscles of the eye except the superior oblique and the external rectus. OCULO- NASAL. Pertaining to or supplying the eye and nose. OCULUS {ok'yu-lus). The organ of vision. O. D. Abbreviation for oculus dexter (right eye). OLD SIGHT. See presbyopia. ONYX [on'iks). An accumulation of pus between the layers of the cornea. OPHTHALMAGRA {of-thal'ma-gra). Sudden pain in the eye^ usually gouty in origin. OPHTHALMALGIA {of-thal-mal' ge-ah). Sudden violent pain in the eye, not the result of inflammation. OPHTHALMALGICUS {of-thal-mal'ge-kus). Belonging to oph- thalmalgia. OPHTHALMATROPHIA {of-thal-viah-tro'fe-ah). Atrophy of the eye. OPHTHALMIA {of-thal'mee-ah). Inflammation of the eye. Ca- tarrhal o., the severer forms. Egyptian o., trachoma. Gonorrhoeal o., Purulent o., acute blen- norrhoea of the conjunctiva; gonorrhceal conjunctivitis. GLOSSARY. 391 Jequirity o., purulent conjunctivitis produced by the instillation of an infusion of jequirit}' into the eye. Metastatic o., chorioiditis due to pyaemia or other form of me- tastatic infection. Neuro-paralytic o., keratitis neuro-para- lytica. O. neonatorum. A specific purulent ophthalmia of infants. Phlyctenular o., phlyctenular conjunctivitis and keratitis. Sympathetic o., a destructive, usually recurrent, plastic irido-cyclitis occurring in one eye as a result of in- jury or inflammation of its fellow. OPHTHALMIC {of-thal'mic). Belonging to or connected with the eye, or with ophthalmia. OPHTHALMITIC. Belonging to ophthalmitis. OPHTHALMITIS {mey'tis, mee'tis). Inflammation of the eye, more especially the globe with its membranes. OPHTHALMOBLENNORRHCEA [blen-ur-rec-ah). A flow of mucus from the eye. OPHTHALMOCARCINOMA ( kahr-sUwh'mah ). Cancer of the eye. OPHTHALMOCELE. Protrusion of the eyeballs. OPHTHALMOCELICUS. Belonging to ophthalmocele. OPHTHALMOCOPIA [koh'pee-ah). Asthenopia. OPHTHALMODYNAMOMETER. An instrument to determine the maximum of convergence. OPHTHALMODYNIA {din'e-ah). Sudden violent pain in the eye not the result of inflammation. OPHTHALMOGRAPHY {mog'rha-fee). A description of the eye. OPHTHALMOLOGY [viol'-o-jee). A treatise on the eye. OPHTHALMOMACROSIS {ma-kro'sis). Enlargement of the eye- balls. OPHTHALMOMALACIA [ma-la' sha). A condition in which, with- out known cause, the eyeball shrinks and becomes soft, but re- turns after a time to its normal state. OPHTHALMOMETER {mom'e-ter). An instrument for measuring the eye ; particularly, an instrument for determining the amount of astigmatism by examination of images reflected from the sur- face of the cornea. OPHTHALMOMETRY ( mom'et-ree). The determination of the re- fraction by the ophthalmometer. OPHTHALMOPATHY [mop'a-thee). Any aff^ection of the eyes. OPHTHALMOPHTHISIS [mof'thi-sis). Wasting of the eyeballs. Phthisis Bulbi. OPHTHALMOPLEGIA {ple'jah). Paralysis of the muscles of the eye. OPHTHALMOPTOMA {mop-to' mah). Protrusion of the eyeballs. OPHTHALMOPTOSIS {mop' to- sis). The progress of ophthal- moptoma. 392 TEXT -BOOK OF OPHTHALMOLOGY. OPHTHALMORRHAGIA ( mor-rha'gee-ah ). Hemorrhage from the eye or orl)it. » OPHTHALMORRHEXIvS [mor-rex'is). Bursting of the eyeball. OPHTHALIMORRHCEA ( mor-ree'ah ). An oozing of blood from the eye. OPHTHALMORRHCEA EXTERNA. Extravasation of blood be- neath the eyelids. OPHTHALMORRHCEA INTERNA. Extravasation of blood within the eye. OPHTHALMOSCOPE [oJ'-ilial-7no-skohp). An instrument, consist- ing usually of a perforated mirror, for examining the interior of the eye, and thus determining the appearance of the media, the condition of the retina, choroid, and optic nerve, and the state of the refraction. The light is reflected by the mirror into the eye, is reflected thence, passes through the hole in the mirror, and enters the eye of the observer, which is placed behind the o. In the direct method of using the o. the latter is held close to the eye examined and an erect virtual image of the fundus is ob- tained. In the indirect method an inverted real image of the fundus is formed in front of the patient's eye by means of an auxiliary lens held before the latter, and this image is then examined by the observer, who stations himself some distance from the patient. OPHTHALMOSCOPIC [mos-kop'ik). Belonging to ophthalmos- copy. OPHTHALMOSCOPY {mos' co-pee). The use of the ophthalmos- cope. OPHTHALMOSTAT [of-thal'mos-tat). An eye-speculum. OPHTHALMOSTATOMETER [sta-tom'-e-ter). An apparatus for determining the degree of prominence of the eyeball. OPHTHALMOTONOMETER {toh-nom'e-ter). An instrument for measuring the tension of the eyeball. OPHTHALMOTONOMETRY {toh-no7n'iit-ree). The determination of the intra-ocular tension. OPHTHALMOTROPE {of -thai' mo-trope). An artificial eye which can be made to rotate about its center and imitate the move- ments of the natural eye. 0PHTHALM0TR0P0MP:TER {troh-pom'e-ter). An apparatus for measuring the movements of the eye. OPTICAL. Relating to the organ of vision. OPTIC AXIS. An imaginary line passing through the centre of the cornea and lens and the point of rotation, to the posterior pole of the eye. OPTIC NERVE. The nerve which forms the communication be- tween the organ of vision and the brain. GLOSSARY. 393 OPTIC DISC. The flat terminal expansion of the optic nerve upon the retina. OPTIC PAPILLA {pa-pill'ah). Same as optic disc. OPTICS. That branch of physical science which treats of light and vision, and the instruments by the use of which the faculty of vision is aided and improved. ■OPTIC THALAMUS {thal'a-mus). Each of two eminences in the anterior and internal part of the lateral ventricles of the brain. The bed of the optic nerve. OPTIC TRACT. The course of the optic nerve before it reaches the commissure. OPTOMYOMETER [mey-om'e-ier]. An instrument for measuring the power of the ocular muscles without exciting accomodation. • ORA SERRATA [oh'ra sehray'tah). The anterior limit of the retina. ORBICULARIS {azvr-bik'yu-lah'-ris) OCULI. The same as orbicu- laris palpebrarum. ORBICULARIS PALPEBRARUM. The circular muscle of the eye- lids. A muscle arising from the outer edge of the orbital process and inserted into the nasal process of the superior macillary bone. It shuts the eye. ORBIT. The bony cavity in which the eyeball is situated. ORBITAL. Belonging to the orbit. ORBIT ARY. Relating to th^e orbit of the eye. ORTHOPHORIA [foh'ree-ah). The condition in which the eyes are properly placed with respect to each other. •ORTHOSCOPE [aui'-tho-scope). An instrument for neutralizing the refraction of the cornea. ORTHOSCOPIC SPECTACLE GLASSES. Two spectacle glasses cut out of a large one in such a way that each eye may be fur- nished with that portion of the lens which is on the eye's axis when the lens is whole. O. S. Abbreviation for oculus sinister (left eye). PACHYBLEPHARUM {pak'ee-blef'iir-um). A thickening of the eyelid, from obstruction of the Meibomian glands. PACHYBLEPHAROSIS {blej-ur-oh'sis). The progress of pachy- blepharum. PAGENSTECHER'S [Pah'gen-stech-erz) OINTMENT— yellow oxide of mercury gr. iv to vii, vaseline oz. i. ■PANNUS. The presence of bloodvessels in the cornea ; a kind of vas- cular keratitis. PANOPHTHALMITIS [pan-of'thal-mey'iis, mee'tis). Inflammation of the entitte eye, ending in rupture and total destruction. PAPILLITIS {pap-il-ey'tiSy ee'tis). Inflammation of the optic papilla. 394 TEXT -BOOK OF OPHTHALMOLOGY. PAPILLO- RETINITIS. Inflaniniation of the papilla and retina. PARABLEPSIS. False vision. PARACENTF:SIS {scfi-tee'sls) CORNEA. Puncture of the cornea.. PARENCHYMATOUS {cn-kim'-a-tus) IRITIS. A form of iritis characterized by discoloration and swelling of the iris caused bj cellular proliferation within its tissues. PAROPSIS (par-op' -sis). A generic term for disorder of vision. PERICHOROIDAL {koh'ree-oy'-diil). Surrounding the choroid membrane. PERIMETER {per-ini'e-tur). A instrument for examining the per- ipheral parts of the retina. PERISCOPIC GLASSES. Concavo-convex and convexo-concave lenses. PERITOMY [pcr-it'o-mcc). Section of the conjunctiva around the cornea. PHACO [fak'oh). Prefix meaning of or pertaining to a lens, espe- cially the crystalline lens. PHACOCYSTA (Jak'o-sis'tah). The capsule of the crystalline lens. PHACOCYSTECTOME [sis-tek'to-me). Rognetta's operation for cataract by cutting out a part of the capsule. PHACOCYSTITIS [sis-tey'tis, tee'tis). Inflammation of the capsule of the lens. PHACOHYMENITIS [hey-7nen-ey'tis, ee'tis). Inflammation of the capsule of the lens. PHACOMALACIA {ma-lay' she-ah). Softening of the crystalline lens. PHACOMETER. An instrument for measuring the curvature of lenses, and so determining their refractive power and, if C3din- drical, their axis. PHACOSCLEROSIS [skle-roh'sis). Sclerosis of the crystalline lens. The process which produces hard cataract. PHACOSCOPE {fak'o-skope). An instrument for examining the im- ages reflected from the anterior and posterior surfaces of the crystalline lens, and thus determining the changes which the latter undergoes in accommodation. PHAKITIS [fa-key' tis). Inflammation of the lens capsule. PHANTASMA. A disease of the eye in which imaginar}^ objects are seen. PHENGOPHOBIA. A fear or intolerance of light. PHOSPHENES {fos'feenz). Subjective phenomena of light caused by external mechanical means. PHOTALGIA {fo-tal'ge-ah). Pain arising from too much light. PHOTOCAMPSIS [fo-toh-kamp'sis). Refraction of the rays of light PHOTODYSPHORIA [dis-fo'-re-ah). Intolerance of light. PHOTOLOGY. The science of light. PHOTOMETER [toni'e-tur). An instrument for testing the light sen8er GLOSSARY. 395. PHOTONObUS [fo-to7i'-o-sus). Any disease of the eye arising from exposure to a glare of light. PHOTOPHOBIA {foh'bee-ah ) Intolerance of light. PHOTOPSIA {top-see' ah). Phosphenes; flashes of light; luminoue rings, etc. PHTHIRIASIS [thur-ee-ey'sis). Blepharitis pediculosa. PHTHISIS (/'<>''5w, Z^^'jw) BULBI. Shrinking of the eyeball. PHYSIOLOGICAL CUP. The normal cup-shaped depression at the entrance at the head of the optic nerve. PHYSOSTIGMINE {fey'soh-stig'meefi). An alkaloid derived from Calabar bean ; it is used as a myotic PILOCARPINE ipey'loh-kahr'peefi). An alkaloid derived from jab- orandi ; it is used as a myotic. PINGUECULA ipmg-gwek'yu-lah). A small yellowish elevation- situated in the conjunctiva near the margin of the cornea. PINK EYE. Catarrhal conjunctivitis. PLICA iply'kah) SEMILUNARIS. A fold of conjunctiva near the inner canthus. POLYCORIA {koh-ree'ah). A multiplicity of pupils. PRESBYOPIA [prez'bee-oh'pee-ah). The condition as a result of age and the consequent inability to accommodate, PRINCIPAL MERIDIANS. The vertical and horizontal meridians of the cornea. PRISM. A prism is a transparent portion of glass or transparent sub- stance between two plane surfaces which are inclined to each' other. PRISM DIOPTRE {dey-op'tur). A prism which deflects a ray of light one centimetre at a plane one metre distant. PROPTOSIS [prop-toh'sis). A protrusion of the eyeball. PROTHESIS [pro-the' sis) OCULARIS. The insertion of an artifi- cial eye. PSEUDO GLIOMA {sew'doh gly-oh'niah). A circumscribed col- lection of pus in the vitreous. PSOROPHPHALMIA {soh'rof-thal'mee-ah). Inflammation of the eye attended with itchy ulcerations, PTERYGIUM {tee-rij'ee-um). A fan-shaped fleshy growth con- sisting of hypertrophy of the conjunctiva, extending from the in- ner angle of the eye to the cornea ; it rarely passes the centre of the cornea. PTOSIS {toh'sis). Drooping of the upper lid. PTOSIS IRIDIS. A prolapse of the iris through a lesion or wound- of the cornea. PTOSIS LIPOMATOSIS ( lih-poh'ma-toh-sis). An extensive accumu- lation of fat in the connective tissue of the upper lid causing it to' droop. 396 TEXT -BOOK OF OPHTHALMOLOGY. PUNCTA LACHRYMALIA {puuiik' ta-Iak-ri-may'lee-ah). The open- ings of the canaliculi. PUPIL {pczv'pil). The central, circular opening in the iris. PUPILLOMETER. An instrument for measuring the pupil. PUPILLOSCOPY. Skiascopy. QUININE AMBLYOPIA. Loss of vision from excessive use of quinine. RED BLINDNESS. The inability to distinguish red. REFRACTION, The deviation of a ray of light from its original di- rection on entering obliquely a medium of different density. RETINA. The ocular expansion of the optic nerve. RETINITIS. Inflammation of the retina. RETINITIS ALBUMINURICA. That form of retinitis caused by albuminuria. RETINOSCOPY. The shadow test of refraction. RETROBULBAR NEURITIS. Inflammation of the optic nerve be- hind the globe of the eye. RHEUMATIC IRITIS [rey'tis, ree'tis). Iritis caused by rheumatism. SCLERA. The external coat of the eyeball. SCLERITIS. Inflammation of the sclera. SCLERONYXIS (nik'sis). Cutting through the retina. SCLEROPHTHALMIA. An opacity of the cornea caused by the sclera lapping over it. SCOTO^lMsko-toh'niah). A blind spot on the retina. SHORTSIGHTEDNESS. Myopia. SKIASCOPY [skey-as'ko-pee). Retinoscopy. SNOW BLINDNESS. Blindness from over-stimulation of the retina by rays reflected from snow. SQUINT. Same as strabismus. STAPHYLOMA [staf'il-oh'mah). Bulging of the cornea. STRABISMOMETER {stra-biz-mom' e-ter). An instrument for meas- uring the degree of strabismus. STRABISMUS {stra-biz'mus.) Cross-eyes. STYE. Hordeolum ; a furuncular afl'ection of the connective tissue of the lids. SURSUMDUCTION {sur'siim-duk'shun ). The power of uniting the two images of the candle seen through a prism with its base down before one eye. SURSUMVERGENS {sur' sinn-vur'jenz). It means tending upward as in vertical squint. SYMBLEPHARON {sim-blef'ur- on). An adhesion between the mucus membrane of the ball and that of the lid. SYNCHYSIS {sing'kih-sis). A mingling of the humors of the eye in consequence of the rupture of the internal membrane and cap- sule by a blow. GLOSSARY. 397 SYNDECTOMY [sin-dek'to-nic). Removal of a ring of conjunctiva around the cornea for the cure of pannus. SYNECHIA {si-nee' kee-ah) ANTERIOR. Adhesion of the iris to tjie cornea. SYNECHIA POSTERIOR. Adhesion of the iris to the lens. TAPETUM. A lustrous, greenish membrane seen in the eyes of many animals. TARSAL CARTILAGE. The cartilages that give the lid its shape. TARSITIS {tahr-sey'tis, see'iis). Inflammation of the tarsal carti- lages. TARSOPHYMA {tahr-so-Jy'mah). A morbid growth or tumor of the tarsus. TARSORRHAPHY {tahr-sor'a-fec). The uniting by suture of any wound of the eyelids near the -tarsus. TARSOTOMY. A cutting of the tarsus, or of the cartilage of the eyelid. TARSUS. The thin cartilage toward the edge of each eyelid giving it firmness and shape. TEARS. The lachrymal secretion. TENONITIS. Inflammation of the capsule of Tenon. TENOTOMY {tee-not'o-mee). Cutting the tendons of the ocular muscles. TINEA TARSI. Blepharitis marginalis. TOBACCO AMAUROSIS. Dimness of vision from excessive use of tobacco. TONOMETER {toh-7iom'e-ter). An instrument for measuring the tension of the eyeball. TRACHOMA {tra-koh'mah). Granulations of the lids. TRICHIASIS [tri-key'a-sis). A disease characterized by irregu- larity in the insertion and direction of the cilia. TYLOSIS {iey-loh'sis). A name for the thickened, ulcerated condi- tion of the lid margins after ulceration. URAEMIC {ewr-ee'mik). AMAUROSIS. Dimness of vision occurr- ing in connection with uraemia. UVEA [ew've-ah). The choroid, ciliary body, and iris. UVEITIS (ew'vee-ey'tis, ee'tis). Inflammation of the uveal tract. VISION. The act of seeing. VISUAL ANGLE. The angle formed at the eye by rays coming from opposite extremities of an object. VITREOUS HUMOR. The gelatinous refracting medium occupy- ing the larger part of the globe. WALL-EYE. A condition ( especially in horses) in which the iris is whitish. XANTHELASMA ( zan' the-laz' mah ). A slightly-raised yellow patch on the skin of ihe lids. XEROMA ( zer-oh'mah). Atrophy of the conjunctiva. 598 TEXT - BOOK OF OPHTHALMOLOGY. XEROPHTHALMIA {zcr-of-thal'mee-ah). An abnormal dryness of the conjunctiva. YELLOW SPOT. The macula lutea. ZONULA OF ZINN. The suspensory ligament of the lens. ZONULAR CATARACT. A form of cataract in which the opacity is limited to a few layers of the lens next to the nucleus. PRESCRIPTIONS THAT HAVE BEEN REFERRED TO MORE THAN ONCE IN THIS TEXT. FORMULA No. 1. R. acid boracic, grs, v. aqua destil., oz, i. Mix and filter. To be instilled into the eye three or four times a day in acute ihyperaemia. FORMULA No. II. R. hydrastin, gr, ss. acid carbolic (pure), gtt, i. morphia sulph., cocaine murias, aa grs, iv. glycerine, dr's, ii. aqua destil., dr's, vi. Mix and filter. A few drops in the eye three or four times a day. To be used in the different forms of conjunctivitis. FORMULA No. III. R. argenti nitras (cryst.), gr, i. aqua destil., oz, i. Mix. To be applied to the edges of the lids in blepharitis marginalis. FORMULA No. IV. R. chloride zinc, gr, i. cocaine murias, morphia sulphas, aa gr's, iv. acid carbolic, gtts, v. glycerine, dr's, ii. aqua rosa. dr's, vi. Mix and filter. To be applied to corneal ulcer once a day with a cotton holder. 400 TEXT -BOOK OF OPHTHALMOLOGY. FORMULA No. V. / R. hydrastin, gr, ss. acid carbolic (pure), gtts, ii. cocaine murias, gr's, viii. glycerine, dr's, ii. aqua hamamelis (dist'd), dr's, vi. Mix and filter. A few drops in the eye when painful in phlyctenular ulcers. FORMULA No. VL R. hydrargeri oxidum flav., gr's, iv. vaselini, oz, i. Mix thoroughly. To be applied to the edges of the lids in blepharitis marginalis. FORMULA No. VIL R. carbolic acid, gtt, i. hydrastin, gr, ss. boracic acid, gr's, x. cocaine hydrochlorate, gr's, iv. glycerine, dr's, ii. aqua hamamelis, dr's, vi. Mix and filter. A few drops in the eye three times a day in the purulent ophthalmias. In all of the above prescriptions where carbolic acid is em- ployed, it should be first added to the glycerine, and the remain- ing ingredients to the aqua destil., aqua rosa, or aqua hamamelis (whichever may be indicated), then the two solutions united and filtered. After any of the above formulas has been prepared and bottled, it should be placed in boiling water, in order that the contents are rendered perfectly aseptic. INDEX. PAGE Accommodation, Loss of '-^^0 Alteratives 326 Amaurosis, Albuminuric 192 Anaesthetics, Local 325 Aniridia 170 Anisometropia 301 Ankyloblepharon 88 Antiseptics 326, 332 Aphakia 39 Aqueous Humor 37 Arcus Senilis 153 Argyll-Robertson Pupil 26 Artificial Eyes 259 Astigmatic Card 295 Astigmatism, 272, 290, Compound A, 273, Mixed A . . 273. 310 Astringents 825 Atropine 323 Bandages 333 Basedow's Disease 56 Black Eye 68 Blepharitis, 69, Causes, Treatment 72 Blepharophimosis 90 Blepharospasm 137 Blind Spot 355 Blood Vessels of the Eye 40, 48 Bones of the Orbit 2 Canaliculus, Operation for slitting up the lower 63 Canal of Schlemm 13 Caruncula Lachrymalis 7 Cataract, 221, Varieties 221, 222, 223 Cataract, Extraction of, 223, Flap Operation, 224, Linear Operation, 225, Von Graefe's Modified Linear Ex- traction, 226, Pagenstecher's Method. 227, Lebrun's Method, 228, Macnamara's Method, 229, Bell Tay- lor's Operation, 230, Wright's Operation, 232, Couching and Reclination 247 Catoptrics 261 Cellulitis, Orbital 52 (401; 402 INDEX. PAGE Chalazion ^-1 Choked Disc 203 Choroid, Anatomy of, 15, Diseases of 170 Choroiditis, 17G, Varieties of, 179, 185, Treatment 183 Choroido-Retinitis 1^3 Ciliary Body, Anatomy of, 17, Diseases of 188 Ciliary Muscles 17 'Ciliary Processes I'J Cocaine '^-5 Coloboma 171 Color-Blindness 319 Conical Cornea 150 Conjugate Focus, Rule for finding 264 Conjunctiva, Anatomy of, 7, Digeases of 93 Conjunctivitis, 95, Serous C, 96, 97, 98, 99, Muco-Puru- lent C, 99 to 104 Cornea, Anatomy of, 13, Diseases of, 121, Fistula of, 152, Wounds of 151 Corneal Staphyloma 149 •Corneal Ulcers, Varieties and Treatment of, 129 to 149 Corneitis 121 Corectopia 171 Crystalline Lens 38 Cyclitis 188 Cyst, Dermoid 75 Cysts of the Iris 170 Danger Zone 20 Definitions 1 Dermoid Cyst 75 Detachment of the Retina 199 Dioptrics 261 Diplopia 277 Disc. Choked 203 Discission or Needling, Operation of 246 Distichiasis 87 Dressings to be used after Wright's Operation for Cataract.. 10 Ectropion 77 Entropion 83 Epiphoria ; 71 Esophoria 274 Enucleation of the Eye 257 Exclusion of the Pupil 26 Exophoria 274 Exophthalmic Goitre 56 External Examination of the Eve 320 INDEX. 403 PAGE Extraction of Cataract 223 Eyeball 10 Fistula of the Cornea LV2 Kitting of Glasses 290 Flap Operation for Cataract 224 Focus, Principal, 263, Conjugate 263 Foramina of the Orbit 3 Foreign Body in the Eye 248 Fovea Centralis 347 Full Correction 300 Glaucoma, 209, Varieties and Treatment, 209 to 215 Glioma 207 Hemianopsia. 355, Temporal H, 355, Nasal H, 355, Homo- nymous or Equilateral H 356 Heterochromia 171 Heterophoria 274 Heterophthalmus 171 Hippus 25 Homatropine 323 Hordeolum 73 Hyalitis 217 Hyaloid IMembrane 40 Hyperopia 266, 290 Hyperesophoria 274 Hyperexophoria 274 Hyperphoria 274 Insufficiencies of Ocular Muscles, Causes and Effects of 275 Introduction of the Nasal Probe 64 Iridectomy 173 Irideremia 171 Iridotomy 175 Iris, Anatomy of the, 20, Diseases of 156 Iris, Congenital Malformations of 170 Iris, Cysts of the 170 Iritis, Varieties and Treatment, 156 to 165 Keratitis, 121, Varieties and Treatment 121, 145 Lachrymal Apparatus, Anatomy of the, 8, Diseases of 60 J^achrymal Duct. Stricture of 62 Lachrymal Gland, Diseases of, 57, Inflammation of, 57. Hypertrophy of. 58, Cancerous Growths of. 59. Fistula of 59 Lachrymal Sac, Abscess of the, 62. Inflammation of 61 Lamina Cribrosa 12 Lebrun's Method 228 Lids. Anatomy of the, 4. Injuries and Diseases of 6^, 69; 404 INDEX. PAGE Linear Operation for Cataract 225 Lippitudo 71 Local Medication in Eye Affections, The Use and Abuse of . . 327 Lymphatic System 43 Macnamara's Method of Cataract Extraction 221) Macula Lutea 347 Madarosis 71 Maddox Test for Insufiiciencies of the Ocular Muscles 317 Media of the Eye 45 Meibomian Glands 6 Metamorphosia 179 Mucocele C6 Muscles of the Eye 45 Mydriatics 324 Myopia. 266, 200, 302, Factitious M 270, 278 Myotics 323 Necrosis of the Orbital Bones 50 Nerve Supply of the Orbital Muscles 48 Neuritis. Optic, 203, Descending N 203 Normal Fundus Oculi as seen with the Ophthalmoscope 345 Occlusion of the Pupil 26, 161 Opacities of the Vitreous 217 Ophthalmia, 102, Purulent O. 104. Plastic O Ill Ophthalmic Therapeutics, General Considerations of 333 Ophthalmometer 357 Ophthalmometry 357 Ophthalmoscopy 340 Optic Disk 35, 347 Optic Nerve. 30, Diseases of. 203, Atrophy of, 206, Tumors of 207 Optic Neuritis 203 Optics, Elementary 261 Orbit. Anatomy of the, 2. Diseases of the O 49 Orthophoria 274 Pagenstecher's Method of Cataract Extraction 227 Papillitis 203 Perimeter, The 352 Periostitis 49 Persistent Hyaloid Artery 220 Persistent Pupillary Membrane 171 Phlyctenular Keratitis 135 Photophobia 137 Photopsia 179 Physiological Excavation 351 Polycoria 172 Presbyopia 267, 290, 310 INDEX. 405 PAGE Pterygium 113 Ptosis 76 Pupil, 24, Seclusion of, 161, Occlusion of 161 Refractive Errors, Methods of Detecting and Correcting 287 Retina, Anatomy of, 27, Ophthalmoscopic Appearances of R, 346, Diseases of R, 190, Detachment of R 199 Retinitis, 190, Varieties of 190, 195 Retinoscopy 335 Sclera, Injuries and Diseases of, 154, Anatomy of S 12 Scleritis 155 Scotoma, 180, 355, Negative S, 355, Positive S, 355, Cen- tral S, 355, Annular S, 355, Scotoma Scintillans. . . 355 Seclusion of the Pupil 4 Sparkling Synchisis 220 Staphyloma, 149, Corneal S, 149, Scleral S 149 Stevens Test for Muscular Insufficiencies 314 Stimulants •* 326 Strabismus 285 Suppuration of the Cornea 244 Symblepharon 88 Sympathetic Ophthalmia 248 Synechia, Posterior 161 Synchisis 219 Tarsus 5 Tests for Insufficiencies 311 Therapeutics of the Eye 323 Tumors of the Optic Nerve 207 Tumors of the Orbit 53 Trial Cases and Frames 291 Trichiasis 71, 86 Tunica Vasculosa 14 Vision 1 Vitreous Humor, 39, Diseases of, 217, Loss of 242 Vitreous Opacities 217 Von Graefe's Modified Linear Extraction of Cataract 226 Wright's Operation for Cataract ^. . . . 232 Xanthelasma 76 Yellow Spot 347 Zone of Zian 19 RETURN OPTOMETRY LIBRARY TO— ^ 490 Minor Hall 642-1020 LOAN PERIOD 1 2 3 4 5 6 ALL BOOKS MAY BE RECALLED AFTER 7 DAYS RENEWALS AAAY BE REQUESTED BY PHONE DUE AS STAMPED BELOW UNIVERSITY OF CALIFORNIA, BERKELEY FORM NO. 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