CHAPTER VII THE CONJUNCTIVA (Part 2)

conjunctiva is at first of an even, bright red color, and is distinguished easily from an inflamma- tory redness by the absence of vessels within it, and its sharp de- limitation. During absorption its boundaries become more diffuse, while the color becomes darker, and then changes to a variety of hues spread diffusely over an area on the surface of the eyeball proportionate to the size of the hemorrhage. The commonest cause of such an effusion is inflammation. Numerous little extravasations are to be seen in the upper, less often in the lower part of the bulbar conjunctiva in many cases of acute conjunctivitis. The next most common cause is traumatism, which may be either direct or indirect. A wound of the conjunc- tiva, whether accidental or operative, is followed usually by an ecchymosis. After a contusion it forms a part of the picture of a “black eye.” An extensive ecchymosis that follows a blow on the head is symptomatic of a fracture of the wall of the orbit, or of the base of the skull; it may appear soon after the injury, or not until after the lapse of some time, and one that appears late on the temporal side is rather suggestive of a fissure that extends into the orbit through the sphenoid bone. When caused by a contusion, a fracture, or a severe compression of the thorax and abdomen, it is associated usually with subdermal ecchymoses in the lids. Hemorrhages occur frequently in children during paroxysms of whooping cough, less often in older persons during coughing, sneez- ing, vomiting, violent exertions, straining at stool, or labor pains. Spontaneous hemorrhages take place, often at night while the pa- tient is asleep, in persons who have brittle blood vessels, when they are apt to cause considerable fright. Such patients ordinarily are elderly and have arteriosclerosis, but sometimes they are young, and then it will commonly be found that the walls of their vessels have been weakened by some such disease as nephritis, syphilis, 118 DIAGNOSIS FROM OCULAR SYMPTOMS diabetes, scurvy, malaria, or purpura. The integrity of the eye is not threatened by a spontaneous subconjunctival ecchymosis, but as it indicates an abnormal condition of the blood vessels it should call for a thorough investigation of the organism; it may be a fore- runner of an attack of apoplexy, or a symptom of some serious general disease. EMPHYSEMA OF THE CONJUNCTIVA When the conjunctiva is lifted up from the eyeball so as to form a tense swelling in which a sense of crepitation is communicated to the fingers when they are pressed upon it, air has entered beneath it. This condition frequently accompanies emphysema of the lids, and is due to the same cause. The only other condition for which it may be mistaken is chemosis, from which it is differentiated by the feeling of crepitation. CHEMOSIS Very often we see a clear or opalescent puffiness of the bulbar conjunctiva, or a denser, yellowish thickening that surrounds the cornea like a wall, sometimes overlaps it, and may involve the transitional folds, but in which no crepitation can be felt. This is chemosis, which is due to a distention of the subconjunctival tissue with serum, often together with an inflammatory exudate. The swollen conjunctiva is crowded for space and a fold of it may pro- trude between the lids. The color changes to red in severe in- flammation, while the pressure of the swollen upper lid tends to drive the cedema downward, when the protrusion between the lids may be that of a large smooth red roll. Should the surface of this protruding fold not be kept sufficiently moist by the secretion that usually flows abundantly over it, a part may become dry from ex- posure to the air, and then ulcerate or necrose. Chemosis is a striking symptom, and while it may or may not indicate a serious lesion, its presence calls upon us to ascertain at once whether its cause is an obstruction to the outflow of blood and lymph due to inflammation or something else, or a morbid condi- tion of the blood. It is a very common early symptom of many inflammations, not only of the conjunctiva itself, but also of vari- ous tissues of the eyeball and of the adjacent parts, it occurs in certain general diseases, and it may also be produced by drugs. We meet with it after both trivial and severe traumatisms to the CONJUNCTIVA 119 conjunctiva, in both mild and severe cases of acute conjunctivitis, and it may be the first sign to warn us of the presence of infection after such an operation as a cataract extraction. It is common in all purulent infections of any of the tissues of the eye, as well as in other inflammations that are not purulent, such as iritis, iridocy- clitis, and glaucoma. We are apt to see it in connection with an inflammation of the lids like a hordeolum, an acute dacryocystitis, a cellulitis of the orbit, a periostitis of the margin of the orbit, or an inflammation of any of the orbital tissues. Associated with oedema of the lids it is not uncommon in frontal sinusitis and eth- moiditis, and is frequently present in cases of facial erysipelas, and of the eruption on the face caused by poison ivy. Less often it occurs when no signs of inflammation are present. When we see an exophthalmos without inflammation, but with chemosis, we suspect that a retrobulbar tumor impedes the outflow of blood from the orbit. Chemosis seems to be caused occasionally by anemia and chlorosis; sometimes it is a symptom of nephritis; in these cases it may come and go, though this is not the rule. An- other fugacious chemosis has been ascribed to atmospheric changes. A regularly recurring chemosis in women may be connected with menstruation, and Roemer has observed it in repeated attacks of migraine. It has been known to occur in urticaria and in trigem- inal neuralgia. <A slight localized cedema may be observed some- times over a paralyzed muscle. A chemosis has been known to follow the internal administration of quinine, or of potassic iodide, and it is ordinarily produced by the instillation of a solution of dionin into the conjunctival sac. The cushion formed by the escape of aqueous beneath the conjunctiva through an aperture in the wall of the globe at the corneoscleral margin, made perhaps by a trephine, is called sometimes a filtration chemosis. Yet, in spite of all these possible causes, we occasionally meet with a case for which we are not able to account. REDNESS OF THE EYEBALL Two or three blood vessels that run separately in the bulbar conjunctiva, and have no morbid symptoms associated with them, are of no importance; they are normal to the individual, who will not feel grateful for attempts to remove them by astringents that simply irritate the eye, or for being induced to wear glasses that 120 DIAGNOSIS FROM OCULAR SYMPTOMS neither conduce to his comfort, nor have any effect upon them. But when we see either a general or a localized redness that is caused by the injection of quite a number of neighboring vessels, we must accept it as showing the presence of trouble somewhere in or about the eye. We should note the location and character of such a red- ness, as well as take into account the history and the accompanying symptoms, for it may be a sign of the presence of a foreign body on the conjunctiva or cornea, of conjunctivitis, keratitis, scleritis, or glaucoma, of an inflammation of the lid, of the lacrimal organs, of the accessory sinuses, or of the retrobulbar tissues. In some of these cases the redness is caused by a congestion of the conjunctival vessels, in others of the episcleral, so the first thing for us to deter- mine is whether the enlarged vessels are in the conjunctiva, in the episclera, or in both. When the redness increases as we pass from the cornea toward the transitional folds and accompanies the con- junctiva when this is moved back and forth over the surface of the globe, the congestion is conjunctival; when it increases in depth toward the cornea and remains in place while the conjunctiva is moved over it, the injection is episcleral. In a great many cases we find both conditions to be present. Many conjunctival troubles give rise to a feeling of discomfort, heat, burning, itching, scratching, or pain, but some do not, and this is one of the reasons why a routine examination should be made .. in every case that comes to our attention. Frequently we find faults in the palpebral conjunctiva when the bulbar appears to be perfectly well, and the reverse is true in some cases. The palpebral conjunctiva may be anemic, hyperemic, or inflamed, when the patient complains of an indefinite feeling of irritation of the eye. Anzmia of the Conjunctiva If the palpebral conjunctiva of the lower lid is pale it is well to evert the lower lip to see if its color confirms the suggestion of a general anemia. I am convinced that anemia itself gives rise to subjective sensations of irritation of the eyes in many cases, for otherwise it is hard to explain why the annoyance persists as long as the anemia, in spite of a careful correction of all refractive and muscular errors and of any other abnormal conditions that may be present, to pass away when the general condition improves. This condition seems to be met with most frequently in elderly persons, in whom it is apt to be obstinate and troublesome. CONJUNCTIVA 121 Hyperzemia of the Conjunctiva When we find the palpebral conjunctiva to be too red, but not looking velvety, and with no discharge beyond possibly a little dry bit in the inner canthus in the morning, perhaps with a moderate amount of lacrimation, we pronounce it hyperemic. Such a condi- tion may be produced by many causes, some of which are hard to detect. We think first of refractive and muscular errors, which furnish a large contingent, but nasal troubles account for many cases, and exposure to wind, smoke, and dust is a prolific source. Sometimes it is caused by lack of sleep, it accompanies hyperemia of the margins of the lids as a rule, and it may be due to such a general disease as the uric acid diathesis, or paralysis of the cervical portion of the sympathetic nerve. Toxic causes must not be for- gotten. It is well known to result from abuse of alcohol and tobacco, but it may be caused by a slight indulgence in either. A single cigar, or a single glass of liquor, has been known to produce an acute hyperemia in rare cases, and habitual indulgence in small quantities may excite a similar chronic condition. The vessels in a distinctly localized hyperemia may diverge toward a foreign body, or may conceal the latter in their midst. CHRONIC CONJUNCTIVITIS The dividing line between a well marked hyperemia and a mild chronic conjunctivitis is not well defined, unless we assume the least demonstrable trace of secretion to mark the transition, but sometimes we find such a trace when none of the other symptoms seem to justify us in pronouncing the condition anything more than hyperemia. On the other hand we may not be able to find any secretion even when the slightly roughened appearance of the palpebral conjunctiva may lead us to say that a chronic conjuncti- vitis is present. The one condition passes over into the other, and all of the causes of conjunctival hyperemia may excite conjuncti- vitis. 'The cardinal symptoms are a chronic redness and swelling of the palpebral conjunctiva, which may vary from a very slight redness and roughening, to a red, uneven surface that tends to ap- pear velvety in the transitional folds, and a sticky mucus that dries on the margins of the lids and may be sufficient to glue them to- gether during sleep. In most cases the bulbar conjunctiva is af- 122 DIAGNOSIS FROM OCULAR SYMPTOMS fected slightly if at all, but sometimes it is injected, and then the eyes appear to be reddish and irritable, while the patient cannot look at a bright light without discomfort and lacrimation. The caruncles and the margins of the lids often are red and prominent. This is distinctly an occupational disease in many callings, in which the eyes are exposed continually to wind, dust, smoke or heat; it is common and very obstinate among farmers, coachmen, automobilists, cooks, and foundrymen. It may be produced by such local causes as a pterygium, a chalazion, the presence of concretions beneath or in the conjunctiva, disease of the lacrimal duct, and in- flammation of the margins of the lids, or it may depend on nasal troubles, or be symptomatic of the uric acid diathesis. In all of these cases the condition is intractable until the cause has been re- moved. It may be, though it is not very commonly, a sequel to acute conjunctivitis. The bacteriological findings vary and are of little importance, except when the diplobacillus of Morax-Axenfeld is present, which produces a characteristic variety of its own. Diplobacillus Conjunctivitis When the margins of the lids are red only at the canthi, and this redness is most pronounced at the inner one, where the caruncle, with perhaps the adjacent skin, is covered by a small quantity of yellowish, tenacious mucus, the presence of the diplobacillus of Morax-Axenfeld is probable, and we have reason to feel very con- fident of the presence of this microorganism if we find very slight changes in the palpebral conjunctiva, often amounting to little more than redness near the transitional folds, and none in the bulbar ex- cept redness near the canthi. The bacilli are short, stout, usually in pairs, and may be found in large numbers in a smear taken from the mucus that covers the caruncle. They withstand drying for a long time, especially when they are in dry secretion, and when they have once settled on the human conjunctiva they set up this mild, chronic inflammation, which is of indefinite length unless properly treated. FOREIGN BODY ON THE CONJUNCTIVA OR CORNEA The symptoms excited by the presence of a minute foreign body on the surface of the eye, pain, photophobia, lacrimation, and a CONJUNCTIVA 123 reddened eyeball, are well known, for there are few of us who have not suffered from them personally. As a rule the patient comes to us with the diagnosis made correctly, and we are able to see the foreign substance caught on the surface of the cornea, or to find it on the tarsal surface of the upper lid. A favorite place for lodg- ment in the latter case is the subtarsal sulcus, which runs horizon- tally about 3 mm. above the margin of the lid. If we do not see it at once it is best for us to employ oblique illumination and a magnify- ing glass, or, better, a binocular loupe, to aid us in making a thorough investigation of the entire surface of the cornea and of the upper palpebral conjunctiva. We are likely to get help from the instilla- tion of a drop of a solution of fluorescin, which usually stains green the slightest erosion of the corneal epithelium, but for some unknown reason it sometimes fails to do this, even when the erosion is plainly visible, so it is not absolutely reliable. In spite of this fact the assistance it affords is so great that it is well to use it whenever we suspect, but cannot see an abrasion of the epithelium of the cornea. A swollen, reddened semilunar fold always invites exploration be- neath it. A group of distended conjunctival vessels that converge toward a certain place in the periphery of the cornea is quite apt to guide us to a minute particle entangled in the corneal epithelium, and a distinctly localized congeries of vessels in the palpebral con- junctiva may conceal a similar one. A minute bit of sawdust, glass, quartz, or other material that is either colorless, or of a pale yellow tint which resembles the basal color of the palpebral conjunctiva, may be extremely difficult to find; sometimes such a substance can be located by a small collection of whitish mucus at a certain point on the surface of the membrane. Not infrequently the sensation persists after a foreign body has escaped, or has been removed, but in such cases an abrasion of the corneal epithelium can be detected almost always by a careful in- spection. It is possible for the subjective sensations to be mislead- ing, and to indicate not the presence of a foreign body, but the onset of an acute catarrhal conjunctivitis, but such a diagnosis is not to be made except when the conjunctival hyperemia is general, rather than localized at any point, no little circumscribed collection of mucus can be found, and no trace of a foreign body, or the slight- est lesion of the corneal epithelium has been detected after a thor- ough, painstaking search. 124 DIAGNOSIS FROM OCULAR SYMPTOMS ACUTE CATARRHAL CONJUNCTIVITIS When a patient complains of a sudden attack of pain, lacrima- tion, and photophobia, soon followed by a watery discharge from the eye, we think at once of an acute catarrhal conjunctivitis, but should not hazard the diagnosis on these symptoms alone. The pain may vary from a vague feeling of discomfort to severe, and some- times is like that produced by the presence of a foreign body. The photophobia may be intense, or absent, but ordinarily is quite mod- erate. The clinical symptoms vary with the severity of the attack. Usually the margins of the lids are reddened, often are a little oedematous, the palpebral conjunctiva is red and smooth, perhaps showing separate enlarged blood vessels if the case is seen early, or the attack is mild, while the transitional fold is very