The commoner diseases of the eye : how to detect and how to treat them

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Preface

Some years ago one of us ventured to write a short treatise entitled Lessons in the Diagnosis and Treatment of Eye Diseases. In the present volume it is intended to amplify this work so that it shall consider ophthalmology from the standpoint of the physician in general practice. It is proposed, mainly by describing only the commoner diseases of the eye (never using a technical term when a simpler word is available), by numerous illustrations, synopsis-headings, and a complete reference-index, to popularize a study that is too often considered difficult and unprofitable.

We are well aware that the conduct of the busy practitioner toward such ocular affections as occur in his practice usually differs from his treatment of most other diseases. The acquirement of even a moderate degree of knowledge respecting diseases of the eye — especially those requiring the use of the ophthalmoscope — necessitates considerable study and frequent chances for observation. The every-day routine of practice affords neither opportunities for the one nor time for the other, and it is not, therefore, surprising that such cases are usually referred to a confrere who makes a special study of them.

While one must admit the advantages that, on the whole, accrue to both patient and medical man from such a disposition of this class of maladies, it is not without its drawbacks.

There is a fairly well-defined and important group of diseases, affecting various parts of the visual apparatus, whose signs and symptoms are especially prone to be overlooked or misinterpreted by the general practitioner simply because he has abandoned the inspection of the eye. In this group are some that call for recognition in tones so loud that they ought to be detected at once by any man who will use his ordinary powers of observation, v/hile others require stricter attention upon the part of the observer. Many of them, too, are by no means simple matters. When not recognized and promptly treated by the surgeon, they go on, in the ordinary course of events, either to a more or less rapid destruction of the organ itself, or to considerable impairment of its function. The claims which the study of this particular set of diseases makes upon the profession become all the more urgent when one reflects that in every instance an early diagnosis may be correctly made by the exercise of the same quality and amount of care and intelligence which arc commonly brought to the investigation, let us say, of affections of the lungs and uterus.

It is not claiming too much, we are sure, of the student of medicine that he should have at least a fairly intimate knowledge of the eye signs and symptoms of disease in general. Chapters

PREFACE V)

on this important subject have been carefully prepared and profusely illustrated, especial stress being laid upon those evidences of systemic involvement that the ocular structures so commonly exhibit.

For the additional assistance of the student a table of contents, giving the headings of each chapter, as well as a cross (reference) index, have been provided so that any subject treated in this handbook mav be readilv consulted.

Many of the illustrations are original with us, while a number are borrowed from well known text-books and treatises, to the publishers of which we are greatly indebted for their use.

The chapters on the relations of ophthalmology to general medicine will be found to resemble in treatment the section devoted to that subject in the text-book on Diseases of the Eye edited by Drs. Hansell and Sweet, because they were both written by the same hand.

Casey A. Wood, Thomas A. Woodruff.

Chicago, Alarch i, 1904.

TABLE OF CONTENTS. Pa(;k

Chapter I. METHODICAL EXAMINATION OF THE EYE

Inspection of the eye — How to evert the lids — Has the patient "crossed eyes" or squint? — Has he ulcer of the cornea? — How to examine the eyes of children without hurting them — The pupil reflexes — The oblique illumination with a lens — The tension or hardness of the eyeball — How to determine the visual acuity or amount of sight — Test types for distant and near vision — How to measure the field of vision with the perimeter— Color vision and color blindness . and how to test them. 23-56

Chapter H.

the normal, the farsighted, the shortsighted and the astigmatic eye.

The normal or emmetropic eye — The abnormal or ametropic eye — The differences between these lie mainly in their shape and size — How the eye focuses or accommodates — Presbyopia or old sight — The path of visual sensations from the retina to the brain — Hypermetropia or farsight, due to abnormally small eyes — Aphakia, absence or loss of the lens — Myopia or shortsight, in which the eyeball is enlarged — How abuse of the eyes causes the eye-coats to stretch — Astigmatism, or abnormal shape of the cornea or crystalline lens — The astigmatic chart — How to correct with lenses errors of refraction resulting from these abnormal conditions 67-80

Chapter III. Page

THE MEASUREMENT OF AMETROPIA — THE FIT- TING OF Ot^ASSES — THE OPHTHALMOSCOPE.

Objective and subjective methods of measuring the refraction — The "test case" used for the subjective determination of ametropia— Fitting of glasses not an easy task — Symptoms of eye strain — The ophthalmometer, or measurer of corneal astigmatism— The ophthalmoscope and how to use it — Its value in the diagnosis of ocular disease — Why it should be in the hands of every physician — Skiascopy, retinoscopy or the "shadow test" the best objective means for measuring refractive errors — How to employ it in the various kinds of ametropia bl-102

Chapter IV. THE COMMONER DISEASES OF THE EYELIDS

1 nc anatomy of the lids — How they protect, lubricate and cleanse the front of the eyeball— The tarsus, the cilia and the Meibomian glands — "Black eye" — Styes — Chalazion or Meibomian cyst and how to remove it — Blepharitis — Eczema of the lid edges — Entropion — How to do a canthoplasty — Other operations for entropion and trichiasis — Ectropion and operations for its relief — Ptosis, or drooping of the upper lid, and how to treat it — Lagophthalmus — Symblepharon 103-136

Chapter V. Page THE COMMONER DISEASES OF THE CONJUNCTIVA

Anatomy — Hyperemia of the conjunctiva and its treatment — Acute conjunctivitis — The various infections of the conjunctiva and their bacterial causes — The pneumococcus, Koch- Weeks bacillus, streptococcus, staphylococcus, gonococcus, Morax-Axenfeld diplobacillus and other sources of conj unctivitis — "Pink eye" — The treatment of infectious diseases of the conjunctiva— Ophthalmia Neonatorum the commonest and most serious eye disease of infancy — How to treat it — Gonorrheal conjunctivitis in the adult 137-166

Chapter VI. THE COMMONER DISEASES OF THE CONJUNCTIVA

(Continued)

Follicular conjunctivitis and its treatment — Trachoma, the most serious form of granular lids — How it produces blindness — Its many complications — Treatment — "Spring" catarrh — Phlyctenular conjunctivitis and its treatment — Pterygium, its cause and treatment — Pinguecula 167-186

Chapter VII. THE COMMONER DISEASES OF THE CORNEA

Anatomy and physiology — Ulcer of the cornea generally due to removal of protecting epithelium and subsequent infection — The pneumococcus — Deep ulcer — Hypopyon — Perforation of the cornea — Treatment — Serpent or spreading ulcer — Ring ulcer at

Page the margin of the cornea — Neuroparalytic ulcer — Herpes of the cornea — Phlyctenular keratitis, a common disease of childhood— Treatment of the foregoing — Interstitial or parenchymatous keratitis — It occurs mostly in children and is due to syphilis or struma — Punctate keratitis, a sign of disease of the choroid or ciliary body — Opacities of the cornea and their treatment — Nebula, macula and leucoma — Artificial pupil — Optical iridectomy — Iridotomy — Tatooing the cornea — Conical cornea and how to treat it 187-230

Chapter VIII. THE COMMONER DISEASES OF THE IRIS

Anatomy and physiology — What produces the color of the iris — The pupil — The uveal tract — Acute iritis — Usually due to rheumatism or syphilis — Posterior synechia, or adhesions of the iris to the lens — How to distinguish iritis from conjunctivitis— Treatment of iritis very satisfactory if given early — Cyclitis or inflammation of the ciliary body. 231-244

Chapter IX

GLAUCOMA — how TO DISTINGUISH THE VARIOUS INFLAMMATORY DISEASES OF THE EYE.

Primary glaucoma — An affection of the intraocular drainage system — The acute form of the disease — Liable to be mistaken for supraorbital neuralgia — The practitioner should always be on the lookout for it — Symptoms of acute glaucoma

PA(;e

— Hardening of the eyeball — Chronic glaucoma — The lesions in this disease — Treatment — Scleritis and episcleritis — An easy method of diagnosing the commoner forms of inflammation of the eye — How to decide whether the inflamed eye is a serious or a simple matter 245-268

Chapter X. THE COMMONER DISEASES OF THE LACHRYMAL

APPARATUS.

The course of the tears from the ducts of the lachrymal gland to the inferior nasal meatus — The anatomy of the lachrymal apparatus — Difference between epiphora and lachrymation — Acute and chronic dacryocystitis practically always due to obstruction of the lachrymal passages — Diagnosis, symptoms and treatment of lachrymal stricture — Passing lachrymal probes — The lachrymal syringe — Extirpation of the sac and removal of the lachrymal gland 269-284

Chapter XI. CATARACT AND OTHER AFFECTIONS OF THE CRYSTALLINE LENS

The crystalline is suspended from the ciliary body behind the lens, in front of the vitreous — Dislocation of the lens — Aphakia or absence of the lens — The various "kinds of cataract — The senile variety the commonest and most important — Hard and soft cataract — The lens an epithelium structure within an unyielding cap-

Page sule, grows heavier, larger and less transparent with age — Diagnosis of cataract — Operations for removal — Iridectomy — Contraindication for operation — Extraction of senile cataract — After treatment. . 285-310

Chapter XII

THE COMMONER INJURIES OF THE EYELIDS, CON- JUNCTIVA, IRIS, CORNEA, LENS, SCLERA AND CHOROID.

Injuries to the lids frequently seen — What constitutes a "black eye" — How to treat it — Incised and other wounds of the lids — Injuries of the conjunctiva — Symblepharon — Burns and other injuries of the cornea and tiow to manage them — Contusions of and blows upon the eyeball — * Hyphemia — Iridodialysis or rupture of the iris — Dislocation of the lens — Deep injuries to the eye, such as rupture of the choroid — Rupture of the eyeball — Sympathetic ophthalmia may follow penetrating wounds, especially of the ciliary region— Injuries of the cornea and how to deal with them — The electro-magnet the most useful means for the extraction of iron and steel from the interior of the eyeball — Migratory, or sympathetic, ophthalmia due to infection of the second eye by microbes and toxins from the injured eye 317-340

Chapter XIII. Page HOW TO PRESERVE THE EYESIGHT — THE FUNDA- MENTALS OF OCULAR HYGIENE

A knowledge of the principles of ocular hygiene necessary to every well informed physician — Care of children's eyes — Stupid pupils often children that are half blind or half deaf — At what age shall a child be sent to school? — The building of school houses and the arrangement of the rooms — Measurements and lighting of the ideal or standard schoolroom — Window shades, blackboards, seats, desks and schoolbooks should be chosen with due regard to the pupils' eyesight — What colors should be used in painting the schoolroom? — The hygiene of adult eyesight— The illumination of offices, public buildings and private houses — The position of the reading lamp — When to avoid the use of the eyes for reading — Dotted veils a cause of eye-strain — Rules for artificial illumination 841-3.16

Chapter XIV

THE COMMONER DISEASES OF THE OPTIC NERVE, ITS PERIPHERAL AND CENTRAL CON- NECTIONS.

The retina an expanded layer of optic nerve tissue — The structure and important parts of the retina — The retinal circulation — The physiology of peripheral vision — The blind spot of Mariotte — The orbital and intracranial divisions of the optic nerve and their cerebral relations — The cortical

Page

center for sight occupies the sides of the calcarine fissure in the occipital lobe — Eye signs of brain tumor — "Choked disk" and its meaning — Its value very great as a symptom of brain disease — Eye signs of meningitis — Blindness from epidemic cerebrospinal meningitis — Pseudo-glioma — Ocular symptoms of multiple sclerosis and tabes dorsalis — Argyll-Robertson pupil — Hereditary ataxia or Friedreich's disease 357-o74

Chapter XV. OPHTHALMOLOGY IN GENERAL MEDICINE AND

SURGERY.

Why the student of general medicine should study the eyesigns of disease — The extreme importance of ocular symptoms in general diagnosis — The eye symptoms (toxic amblyopia) set up by indulgence in tobacco and alcohol, by lead poisoning and by methyl alcohol — The treatment of toxic amblyopia — Ocular rheumatism — The eye signs of gout, gonorrhea, measles, syphilis, dyspepsia and diseases of the reproductive organs — Affections of the eye in tuberculosis, simple anemia, leukemia, hemorrhages, nasal diseases and diseases of the ear 375-386

Chapter XVI. THE OCULAR COMPLICATIONS OF CERTAIN SYS- TEMIC DISEASES

The ocular lesions that accompany or follow smallpox, e. g., ulcer of the cornea — The

CONTENTS IS

Page oculomuscular pareses of diphtheria — The eye complications of influenza, malaria, typhoid fever, rickets and diseases of the vascular system — Retinal pulsations in aortic insufficiency — Retinal embolism and thrombosis 3^^7-396

Chapter XVII

HEADACHE FROM EYE STRAIN — OCULAR HEAD- ACHE— THE OCULAR SIGNS OF CERTAIN GENERAL DISEASES.

Headacne from eye strain very common — Nearly always a frontal headache — Causes of ocular headache — How to distinguish an eye headache from others that resemble it — Treatment of it — Exophthalmic goitre, Graves' or Basedow's disea'se — The eye signs very important and valuable in diagnosis — The ocular signs in epilepsy — Migraine not an affection of the visual apparatus although it usually presents characteristic eye symptoms — The ocular signs of hysteria — Reversal of the color field — Hysterical amblyopia — Monocular diplopia^Hysterical photophobia and blepharospasm — Traumatic hysteria — Ihe eye symptoms of Bright's disease — Albuminuric retinitis — The ocular signs of diabetes — Diabetic cataract — The commoner tumors of the eye — Glioma retinae 397-424

Chapter XVIII. THE COMMONER DISEASES OF THE EYE MUSCLES

Anatomy and physiology — The rotation center of the eyeball — Six orbital and two

Page

intraocular muscles — How to memorize their nerve supply as an aid to the diagnosis of cerebral and spinal lesions — Heterophoria and its meaning — The various forms of muscular imbalance — Tests for and treatment of heterophoria — Squint or strabismus — How it differs from paralysis of the eye muscles — Convergent and divergent squint — Symptoms and treatment — Tenotomy and advancement of the external ocular muscles — Paresis and paralysis of the eye muscles — Double vision and vertigo the chief symptoms — Syphilitic and rheumatic lesions the chief causes — Peripheral and central forms of tne disease — Tabes and diphtheria — Treatment — Nystagmus and its causes 42V450

Chapter XIX. THE COMMONER PATHOGENIC BACTERIA THAT

INVADE THE EYE.

Numerous bacteria, pathogCQ'c and benign, inhabit the normal conjunctival sac — Slight traumatisms or local irritations permit them or their toxins to invade the tissues beneath the protecting epithelium — They constitute an important cause of ocular inflammations — The staphylococcus— The streptococcus — The gonococcus of Neisser the special cause of gonorrheal conjunctivitis in adults and in ophthalmia neonatorum — Tne pneumococcus the special bacterium of spreading ulcer of cornea— The Koch-Weeks bacillus responsible for "pink eye" — It is doubtful whether

Page

the trachoma bacillus has been isolated — Mixed infections — Toxins often as virulent as the bacteria that excrete them — The environment of much importance in determining the virulence of bacteria 451-456

Chapter XX. REMEDIES COMMONLY USED IN OPHTHALMIC

PRACTICE.

Local blood-letting — Leeches, natural and artificial— The appHcation of dry and moist heat — This remedy mostly used in deep-seated inflammation of the eye — The use of cold — Moderately cold applications in superficial ocular inflammation — Massage of the lids over the eyeball — Subconjunctival injections — How to irrigate the eye — The use of the medicine dropper — How to instill single drops — Poultices rarely useful in eye diseases — The "rest cure" as applied to the eyes — Protective glasses, goggles and bandages — Their various forms and how to apply them — Mydriatics and cycloplegics — Cocain, atropin, euphthalmin and homatropin — Atropin and other powerful cycloplegics — Miotics and their uses — Holocain, cocain and other local anesthetics — Silver nitrate, argyrol and protargol — Zinc and copper sulphates — Boric acid, formalin, bichloride, and other disinfectants — Dionin — Suprarenal capsule and its extracts — The yellow oxide of mercury and its ointments— The preparation of the patient in ophthalmic operations 457-491

Chapter I. Methodical Examination Of The

EYE.

Inspection of the eye. — How to evert the lids. — Has the patient "crossed eyes" or squint? — Has he ulcer of the cornea? — How to examine the eyes of children without hurting them. — The pupil reflexes. — The oblique illumination with a lens. — The tension or hardness of the eyeball. — How to determine the visual acuity or amount of sight. — Test types for distant and near vision. — How to measure the field of vision with the perimeter. — Color vision and color blindness and how to test them.

Just as one studies the conditions under which the healthy lungs and heart subserve their respective functions before proceeding to an investigation of the departures from health to which these organs are subject, so it is well to make a study of the normal eye. The physician should cultivate this habit of observation in the case of the visual apparatus particularly, because so much information as to its condition— whether normal or abnormal — can always be learned by simple inspection.

To be of the greatest value, such cm examination should be methodical and every case should be examined in the satne order. Of course, where the patient's condition is so obvious that it would be mere waste of time to follow out a program including all the parts of the eye, this rule may be modified ; but it is the safest to run

LANE UBRARY. STANFORD UNIVERSE over the whole ground, so far as possible, in the great majority of instances.

The common and probably the best plan that can be adopted is that of proceeding from without inward, bearing in mind, meanwhile, as many as possible of those diseased conditions which one might expect to find in the particular locality under examination.

The objective examination of the eye should be begun by carefully inspecting the superficial structure and parts surrounding that organ. The patient is to be seated in a chair facing a window through which a good illumination can be obtained.

The lids are to be examined for any irregularity in their outline, for distended vessels, edema, thickening, redness or tumors (such as cysts) of the Meibomian glands (Chalazia) — and for scales, crusts or ulcerations along their margins (blepharitis). It should be noted if they are in close apposition to the eyeball, and whether their margins turn out (ectropion), or turn in (entropion) , or if there is inability to close the lids (lagophthalmus) , or drooping of the upper lid (ptosis).

The cilia or eyelashes should next be inspected to see if any are misplaced, or if they curve inward (trichiasis). The position and permeability of the puncta should be ascertained. Pressure should be made over the

EXAMINATION 0 lachrymal sac in the endeavor to squeeze out through the puncta any fluid (mucus or pus)

that may be retained therein. It should be noted if the conjunctival sac contain any secretion, and if so whether it is mucous or purulent; whether the tears accumulate in the corner of the eye, overflow and run down over the cheeks (epiphora).

For a thorough examination of the miicous lining of the lids and eyeball {conjunctiva), 'the former should be everted and their inner surfaces inspected for any undue redness, roughness or other abnormality.

The lower lid is everted by placing the tip of the thumb upon the skin near its margin and drawing it downward, at the same time pressing backward, and telling the patient to roll the eyeball upward.

The eversion of the upper lid is somewhat more difficult, and is accomplished in the following manner. The patient is told to look down during the zv^hole time required for everting the lid. The surgeon stands behind the operating chair. The forefinger of the left hand is placed upon the upper lid just below the eyebrow and the lid drawn by the finger tip up and away from the eyeball in such a manner that the cilia point upward. Tlie eyelashes are then grasped by the thumb and forefinger of the opposite hand,, without touching the globe. The patient is now directed to continue looking downward, the lid is drawn down and away from the globe, while the forefinger, which was in position

METHODICAL EXAMINATION OF THE EYI m

below the hrow, is slipped to the upper in ihe tarsal cartilage and pressed dowiuv

argin of ard. At

E