CHAPTER VII THE CONJUNCTIVA (Part 1)

CHAPTER VII THE CONJUNCTIVA The conjunctiva forms a sac open along the palpebral margins, which lines the inner surfaces of the lids, is reflected from them to the eyeball, and covers the anterior portion of the sclera to the edge of the cornea. Its epithelium continues over the surface of the latter. It is smooth and lustrous throughout, presents the charac- teristics of a mucous membrane only in its palpebral portion, where it is closely adherent to the subjacent tissues, and is of a pinkish color, varying to red at the margins of the lids and at the ends of the tarsus, while the transitional and bulbar portions are attached very loosely to the tissues beneath them, and are translucent, almost colorless, so that the white sclera is seen plainly through the latter. No description is adequate to convey to the mind a definite idea of its normal appearance unless it is. supplemented by observation, opportunities for which are abundant for all who will avail them-- selves of them. Within the inner canthus is the caruncle, a small, reddish body, an islet of skin provided with glands and hair, which rests partly on a crescentic, vertical fold of the bulbar conjunctiva called the semilunar fold. Quite a number of lesions and diseases are common to both the conjunctiva and cornea, so that they may be described with equal propriety under either of these tissues, such as a tumor of the corneoscleral margin, or a phlyctenular kerato- conjunctivitis, and other troubles that are considered strictly con- junctival are apt to be associated with corneal complications that form important features in the symptomatology, like the pannus of trachoma, but it seems wiser to describe the diseases of the con- junctiva and cornea separately for the sake of clearness, although in some of these cases the distinction may seem artificial, and in others the most prominent symptom may not lie in the tissue that is the principal seat of the disease. : Before we look at the conjunctiva we have noticed whether the lids are swollen or not, whether any secretion is to be seen on their margins or in the canthi, and whether there is any abnormality ob- servable in the neighboring tissues. The conjunctiva is the first part of the eyeball to receive our attention, and, after observing what is to be seen through the palpebral fissure, we separate the lids 110 CONJUNCTIVA - 111 with our fingers, have the patient look down and then up, so as to bring into view all of the cornea, all of the sclera and bulbar con- junctiva that can be exposed, and then evert the lids to examine the palpebral conjunctiva. To evert the lower lid we place a finger on its skin and draw it down so as to expose the palpebral conjunctiva and the lower transi- tional fold. To evert the upper lid we seize the lashes about the junction of the middle and inner thirds of its margin, draw the lid gently out from the eye until the upper edge of the tarsus alone touches the eyeball, tell the patient to look down, and as he does so press gently on the upper edge of the tarsus with some blunt instru- ment, like a probe or a finger, when the lid everts instantly. No pain and very little annoyance is felt when this is done properly, and this is appreciated by anyone who has endured the results of clumsy efforts to evert the lids by force without sufficient attention to these details, perhaps at the hands of those who ought to know better. Force is seldom necessary, except when marked pathologi- cal changes are present in the lid, but then may be needed. When the lashes are absent the margin of the lid itself is seized at the place mentioned. By this maneuver all parts of the conjunctival sac are brought into view except the upper transitional fold, which seldom needs to be seen, but may be brought to light by seizing the everted lid with a pair, or better two pairs, of forceps and evert- ing it again. A less perfect view may be obtained by slipping an elevator beneath the everted lid and lifting it out from the eyeball. While we are making this examination we note any deviation from the normal that may be seen in any of the tissues that are visible, and observe whether it is accompanied by signs of inflamma- tion or not. The location of any abnormal condition is perceived at once, as a rule, though sometimes a painstaking inspection with the aid of oblique illumination and a magnifying glass is necessary, but it is not always easy to recognize its exact nature. Ordinarily this inspection of the conjunctiva is brief, but we should train our eyes to follow a routine course in order that nothing may be over- looked. THE CARUNCLE The caruncle may be small or large, and has been found double in a few cases. Its hairs are white or colorless, and very fine as a rule, but occasionally they are long, curved, and irritate the con- 112 DIAGNOSIS FROM OCULAR SYMPTOMS junctiva with their points. When the caruncle appears red and angry the first cause we are likely to think of is eyestrain, espe- cially that caused by faulty convergence, but we should never fail to look for the presence of a foreign body, or of an irritating eye- lash. Abscess and all manner of tumors have been known to occur in the caruncle, but such cases are rare. THE SEMILUNAR FOLD The semilunar fold is implicated more or less in many inflamma- tions of the conjunctiva and may disappear in the body of a pteryg- ium. When it is hypertrophied it may extend a considerable dis- tance toward the cornea. In rare cases we find it inflamed and swollen when none of the surrounding tissues appear to be affected, and then we are apt to find a foreign body beneath it, or an eyelasb that is scratching its surface. CONGENITAL DEFECTS OF THE CONJUNCTIVA Congenital defects are uncommon. The caruncle may be wanting when the eyeball is abnormally small or absent, the bulbar portion may exhibit an area of thickening in the region of the palpebral fissure, the entire conjunctiva is apt to be absent in cryptophthal- mos, and there may be an adhesion of the conjunctival margins of the lids so as to produce a blepharophimosis of greater or less extent. Perhaps dermoid should be considered a congenital defect. PINGUECULA Our attention may be arrested by a round, oval, or triangular elevation of a yellowish gray color, looking like a bit of fat, at the inner or outer margin of the cornea in the horizontal meridian of the palpebral fissure. This pinguecula is composed of conjunctiva and subconjunctival tissue that has undergone hyaline degeneration and is of no pathological importance, except that possibly it may become the starting point of a pterygium. It may be mistaken at first for a solitary phlyctenule, especially when a few blood vessels radiate toward it, or for a pericorneal nodule of vernal catarrh, but the absence of all of the subjective symptoms characteristic of these diseases, as well as of all inflammatory symptoms, together with its location and its fatty appearance, usually leave little doubt as to the CONJUNCTIVA 113 diagnosis. If it has been known to exist for some time, or if it re- mains unchanged for two or three weeks, all possible doubt is dis- pelled. SPOTS ON THE CONJUNCTIVA When we see one or more small, round or oval, reddish, brownish, or black spots in the conjunctiva which are not accompanied by in- flammatory symptoms, we should inquire concerning any previous inflammation of the eye, for such spots may be left after the healing of pustules, or of mucous patches on the conjunctiva. In the ab- sence of such a history it may mark an accumulation of nevus cells, and we should determine whether it is increasing in size or not, for it may be the starting point of a sarcoma. It is well to say here that whenever we feel any doubt as to the nature of any conjunctival spot or growth it is best to have it excised and examined under the microscope, for often this is the only way in which a positive diag- nosis can be made and malignancy excluded. PTERYGIUM When we see a triangular growth which has its base at the in- ternal or the external canthus and its apex at a point on the cornea, and can pass a probe beneath it into a cul de sac at the limbus, both from above and below, we have to deal with a pterygium. The conjunctival portion is called the body, the part on the cornea the head, and that at the limbus the neck. If the body is fleshy and red, while the head has a gray, swollen, gelatinous looking margin, the pterygium is advancing; when growth has stopped the body be- comes thin and membranous, and the gelatinous border of the head becomes thinner. The apex progresses toward the center of the cornea, which it rarely passes, and the head remains attached to this tissue by a narrow strip along its middle line. The body blends with the conjunctiva and may obliterate the semilunar fold when it is on the inner side of the eyeball, as it is in the majority of cases. Sometimes two pterygia are present in the same eye, one on the inner, the other on the outer side of the cornea, and four have been known to occur simultaneously in one person. The subjective symptoms caused by pterygium vary. Sufficient astigmatism may be produced to impair vision, yet in many cases there is no complaint of this nature until the head of the pterygium has advanced so far as to interfere mechanically with the sight. The 114 DIAGNOSIS FROM OCULAR SYMPTOMS disfigurement alone is apt to bring the patient to the surgeon. In other cases the conjunctiva is rendered so tense by it as to damage the motility of the eye and cause diplopia when the patient looks in a certain direction, or the growth may so irritate the conjunctiva as to induce catarrhal trouble. Furthermore the involvement of the semilunar fold may so interfere with the lacrimal lake as to cause epiphora. False Pterygium A picture somewhat similar to that produced by pterygium some- times is presented by a fold of conjunctiva that has become adherent to the cornea as the result of a burn, or of some violent inflamma- tion in which the two surfaces were made raw and brought into con- tact. Such a false pterygium may be found attached to any part of the cornea, coming from any direction, and usually is associated with scars. The differentiation is made easily from the history, its location, the presence of other scars, the absence of a gelatinous looking margin to the head, the fact that it shows no tendency to advance, but has always been of the same size since it was noticed first, and the failure of an attempt to pass a probe beneath its mar- gin, as the fold of conjunctiva is adherent throughout to the surface of the cornea. TUMORS OF THE CONJUNCTIVA A tumor of the conjunctiva is recognized readily as such in the great majority of cases, but it is not always easy to tell whether it is benign or malignant. A reddish, yellowish, or grayish tumor at the corneoscleral margin, lying partly in the conjunctiva, partly in the cornea, which is a favorite situation, may be a dermoid, an epithe- lioma, or a sarcoma. If its surface is rather dry, downy, or hairy, and the history indicates that it was congenital, the diagnosis of dermoid is positive; if the surface is smooth and moist it may be any one of the three, with the probabilities in favor of epithelioma if it appeared as a small, hard, painless neoplasm in an elderly per- son, and has grown slowly. A sarcoma is more apt to be pig- mented, and more likely to overlap rather than to invade the cornea, but occasionally we meet with a pigmented epithelioma that over- laps the cornea, so the differentiation cannot be made in this man- ner with any certainty. If it was congenital it probably is a der- moid. If it has appeared recently in a young person, the chances CONJUNCTIVA 115 are that it is a sarcoma. When we find a smooth, flat tumor in some other part of the bulbar conjunctiva, where it is freely mov- able over the sclera, we still have to bear epithelioma in mind if the patient is elderly, but in younger persons it is more likely to be a sarcoma, a fibroma, a dermoid, a lipodermoid, a lipoma, or an os- teoma. The presence of some hairs, or the peculiar consistence may render the diagnosis of dermoid, lipoma, or osteoma easy, but in most cases we cannot be sure of its exact nature until after it has been removed. A favorite situation of the dermoid is in the upper outer part, between the external and superior recti, and in the same place we sometimes meet with a lipoma that is connected with the orbital fat by a pedicle, or can feel the tip of a hypertrophied lacri- mal gland. The latter can be pushed back beneath the rim of the orbit leaving the conjunctiva unaffected, while we have difficulty in doing this with a dermoid or a lipoma. - The conjunctiva moves with the dermoid, and with the lipoma if the latter is in its tissue, otherwise it slides over the surface of the tumor. Im rare cases we may see near the inner canthus a dark red, or bluish red growth that is formed of a congeries of blood vessels. This is an angioma and is not hard to recognize. A smooth pedunculated tumor cov- ered with conjunctiva is a polyp, and will guide us to a lesion caused by a foreign body, or to a wound. A nodulated, pedun- culated tumor with a fissured surface that bleeds easily is a papil- loma. Soft, irregular granulations, that bleed readily and are not covered by conjunctiva, sometimes spring up about a wound and indicate its presence. Cysts of the Conjunctiva A cyst is recognized at once when we see the surface of the con- junctiva elevated by a little sac of clear or yellow fluid. A cyst with clear, watery contents, which is situated superficially in the bulbar conjunctiva, probably originated from a dilated lymphatic. Quite often a number of small, transparent beads of this nature are to be seen between the cornea and the canthus in the region of the palpebral fissure; these are known as lymphectasize and cause little or no trouble, except sometimes to worry the patient. Other cysts result from pathological changes in the epithelium, or the agglutination of little folds of the conjunctiva; such are to be seen rarely in the head and neck of a pterygium. Others are of trauma- tic origin and have followed wounds; some familiar examples of 116 DIAGNOSIS FROM OCULAR SYMPTOMS these are the cystoid cicatrix sometimes seen after an iridectomy or a cataract extraction, and the cushion produced by trephining the sclera. When the wound has pierced the conjunctiva alone we are unable, as a rule, to determine by clinical inspection whether the cyst has been caused by the agglutination of folds, by the trans- plantation of epithelial cells into the subconjunctival tissue, or by the presence of a foreign body. Similar cysts are found on the palpebral conjunctiva, as well as others caused by an occlusion of the ducts of Krause’s glands. A bluish, cystlike spot in the con- junctiva over a Meibomian gland marks the presence of a chalazion. The possibility of a cysticercus should be borne in mind when we find a large cyst in the conjunctiva, though this parasite seldom is found anywhere in the eye in this country. While the cyst is still transparent the head of the cysticercus may be seen within it; later, when its surface has become inflamed and opaque, it should be incised and searched carefully. SYMBLEPHARON Quite frequently we find an agglutination of more or less of the palpebral to the bulbar conjunctiva. This is called a symblepharon. The usual cause is a burn which denuded the two surfaces so that they became adherent while they lay in contact afterward, but the same result sometimes is produced by a wound, by a purulent or membranous conjunctivitis, by trachoma, and by pemphigus. XEROSIS An abnormally dry condition of the conjunctiva, or of the con- junctiva and cornea, which has been produced by prolonged ex- posure to the air, by cicatrization that has followed local inflamma- tion, or by certain depleted states of the body, is called xerosis. It may be partial in lagophthalmos and in ectropion, but, as a rule, the entire surface is involved. It is met with in two forms, a milder and curable one in which the epithelium alone is affected, and an incurable one in which the conjunctiva has been changed into cicatricial tissue. The epithelial form appears together with hemera- lopia in some cases of starvation, chronic alcoholism, and certain chronic diseases of the liver, as well as in desperate cases of cholera, cholera infantum, dysentery, typhoid fever, scarlet fever, puerperal fever, and congenital syphilis. The worst form is seen after the CONJUNCTIVA shkeg conjunctiva has been destroyed by cicatrization following severe burns, trachoma, pemphigus, or the worst cases of membranous conjunctivitis, when the membrane cannot be moistened by the lacrimal fluid that flows over it in the cases in which the function of the lacrimal gland is preserved to a greater or less extent. The subjective symptoms are those of an intense feeling of dryness. SUBCONJUNCTIVAL HEMORRHAGE An effusion of blood beneath the