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APR 25 1899
There is no disease of the eye that the oculist is called
As regards the anatomy it must be remembered that the
clitis separately, and then show how a simple iritis is intensi-
The symptoms of iritis are due to either hyperaemia or
volved in the inflammation. The discoloration is less marked.
in dark eyes.
The contracted pupil is a necessary result of the dilated blood vessels and spasm of the sphincter, consequently the pupil will not respond to light. Atropia acts slowly and less thoroughly, and is often made to act better by combining it with cocain, as the latter agent contracts the vesseis and empties them of blood. There is also ciliary injection, photophobia, increased lachrymal secretion and more or less pain.
The symptoms of congestion may be present without exudation. Simple hyperaemia of the iris is seen in ulcers of the cornea, and in foreign bodies of the cornea, more especially if these are located near the center. In fact an ulcer or a foreign body that remains for any length of time in the center of the cornea is quite likely to give rise to an actual iritis.
Exudation into the tissue of the iris makes it appear swollen and the change of color more marked than in simple hyperaemia. There is sometimes an exudation membrane covering the entire anterior surface of the iris and also the pupil, and this adds to the obscuration and change of color.
If this exudation becomes organized it closes the pupil and becomes connected with its margin, constituting what is known as a pupilary membrane. This condition is known as ccclusion of the pupil.
The exudation which is poured out into the posterior chamber manifests himself by the adhesions which it forms between the iris and the capsule of the lens, and are called posterior synechia. In their formation it is not the iris proper but the layer of pigment covering its posterior surface, that becomes adherent to the lens capsule; therefore the tags jutting out when the pupil is dilated with atropia look brown, and the small spots that remain upon the lens capsule after the synechia have been broken up, and which are arranged in a circular form, are of the same brown color. This circle is narrower than the normal pupil because it was formed when the pupil was contracted by the iritis. These spots never disappear.
If adhesions take place throughout the entire circumference of the pupil, we have an annular posterior synechia. This seldom forms all at once, and is the result of recurrent iritis. This completely shuts off the anterior from the posterior chamber, and the condition is known as seclusion of the pupil. Occlusion and seclusion of the pupil often take place
together, but they frequently occur separately and then have very different effects upon the eye. Occlusion of the pupil interferes greatly with the sight, but does not otherwise endanger the integrity of the eye. Seclusion of the pupil does net of itself interfere greatly with the vision, but frequently leads to increased tension and this produces blindness and frequently the loss of the eye.
If exudation into the posterior chamber is very extensive it leads to adhesions between the lens capsule and the entire posterior surface of the iris, forming total posterior synechia. Such excessive exudation does not take place in simple iritis, but only when complicated with cyclitis.
The exudation of cyclitis is thrown out in the anterior and posterior chambers and in the vitreous. The most characteristic exudates of cyclitis, are the so-called precipitates, which are arranged in a triangular form upon the posterior surface of the cornea. The base of the triangle is downward and the apex near the center of the cornea. Frequently the base looks like a mass of exudate, and the dotted appearance shows only toward the apex where the exudate is thinest. As I have said before, exudation into the posterior chamber if extensive, leads to adhesions between the entire iris and the lens capsule. As the exudate shrinks it draws the iris backwards towards the lens, the anterior chamber is therefore deeper than normal, especially at its circumference.
Exudation into the vitreous appears in the form of opacities, and resulting diminution of vision, and if extensive may by their shrinking cause shrinking of the entire globe and complete loss of vision.
The tension of the eye in iritis is usualy unchanged, but in cyclitis, during the acute inflammatory stage, it is frequently increased, and later, if the exudation is extensive, we get the tension diminished below normal from shrinking of the exudate.
Cyclitis, like iritis, is accompanied by symptoms of inflammation, consisting of injection, pain, photophobia and profuse lachrymation. The intensity of these symptoms is usually governed by the acuteness and severity of the inflammation.
Chronic cases occur where symptoms of inflammation are altogether wanting. On the other hand there are cases of irido-cyclitis where the pain is most intense and accompanied by vomiting and febrile movements. These cases, if there is an increase of tension and a partly dilated pupil, may be mis
taken for glaucoma, or on the other hand, glaucoma may be mistaken for iritis, and if atropia is used the sight is quite sure to be lost.
We diagnose iritis when the symptoms are the mildest of the above described inflammation; but in those cases where there is edema of the lids which never occurs in simple iritis; when the eye is painful to touch; when the deposits are present upon the posterior surface of the cornea; when the disturbance of vision is greater than can be accounted for by the opacities in the anterior chamber; when the tension is changed, either increased or diminished, we are justified in the diagnosis of irido-cyclitis. Uncomplicated or simple cyclitis occurs but seldom, and then only in a chronic form. The symptoms are sluggish pupil, deposits upon the cornea and in the vitreous, and the inflammatory symptoms are slight or altogether wanting
Etiology.-Acquired syphilis is by far the most common cause of iritis. In my experience it causes more than one-half of the cases of iritis. Hereditary syphilis and scrofula are among the frequent causes. Gonorrhea causes iritis only through general infection, and may then be classed as one form of rheumatic iritis. Iritis also occurs in acute articular and chronic rheumatism. In gout and diabetes and acute infectious diseases. There are also cases that can be traced to no apparent cause. Decayed and inflamed teeth should always be looked after, as I have seen very obstinate cases rapidly recover after the removal of very bad teeth. Injuries of all kinds may give rise to iritis, especially perforating wounds of the eye. An eye suffering from irido-cyclitis may give rise to sympathetic irido-cyclitis in its fellow.
Diagnosis. These are the principle causes, and I have already given most of the points of diagnosis. We must differentiate between iritis and conjunctivitis, and between iritis and glaucoma.
Iritis need never be mistaken for conjunctivitis if we are careful in our observations. In conjunctivitis there is always a secretion of pus or muco pus, which does not occur in iritis. The pupil responds to light as quickly as its fellow. There is no change of color. There is no pain or tenderness, but rather a feeling as though there were some small object in the
In acute glaucoma there is more difficulty in diagnosis. There is pain; febrile movement and vomiting; change of color; dimness of vision; haziness of the cornea and intense
congestion. These may occur in iritis. There is also contraction of the visual field, increase of tension, a sluggish pupil which is either partly or widely dilated, halos and cupping of the optic disk. The latter symptom can only be seen when the media are clear. These symptoms seldom occur in iritis. It is true that in some cases of irido-cyclitis we get increase of tension, a sluggish and partly dilated pupil. It is here that we must be careful. Glaucoma is a disease of middle age, and this point, if borne in mind, is of frequent help. Iritis may occur at any age, though I have seldom seen it in the very young, except from traumatism. Glaucoma never occurs in the young. I have never seen a case under thirty years of age. Vomiting is a frequent symptom; sudden blindness, lasting for a few seconds, is sometimes a prominent symptom. Vomiting is not a frequent symptom of iritis, and sudden blindness does not occur. In case of doubt don't use atropia, be sure of your diagnosis before you use it; do not use it promiscuously for every inflamed eye that comes to you; do not use it in ulcers of the cornea unless there are symptoms of irritation of the iris. This occurs most frequently in central ulcers and then it should be used often enough to keep the pupil dilated.
A small cinder, a piece of steel or a foreign body of any description, if lodged in the center of the cornea, will produce symptoms of iritis; and if allowed to remain may produce actual iritis. The reason for this in central lesions is obvious, the irritation being in the center calls blood from all sides towards the center, and we, therefore, get a general congestion of the ciliary body and iris and of the circumcorneal zone. This congestion is only partial if the lesion is at the margin of the cornea. Therefore in central ulcers of the cornea and in injuries of the center of the cornea, we must watch for iritis, and I think it is a good plan in central ulcers to always use atropia from start to finish.
Treatment of iritis.-Must be local and constitutional. We must, if possible, find the cause. We frequently find patients with iritis who deny ever having had a chancre and who will admit that they have had falling of the hair and brows, rheumatic pains, soreness of the shins and sternum, enlarged glands, etc., iodid of potassium and mercury have a wonderful effect upon a great many of these non-specific cases(?). Gout, rheumatism, diabetes, bad teeth, etc., must all be looked after and receive proper treatment.
Locally, atropia is the sheet anchor. Cocain, hot or cold