cicatricial changes. The prognosis is better than that of gonorrheal conjunctivitis of adults, yet it is very grave, as the records of all institutions for the blind can testify. The onset of the disease should be guarded against carefully, not only through cautious antisepsis during labor, and the subsequent protection of the eyes from any possible infection, but also by cleansing the eyes with close attention to details. When the genital passages of the mother are known or suspected to be infected with gonorrhea the instillation of a drop of a two per cent. solution of silver nitrate into each conjunctival sac, as recommended by Crede, should never be omitted, even though the severe reaction that follows once in a while may render it undesirable for routine use when there is no warrant for suspicion of such disease in the mother, but at least a one per cent. solution should always be employed. In addition to this the eyes should have their first bath from a basin of clean water, and none of the water used to bathe the body should be allowed to come in contact with the eyes. When we separate them a small quantity of thin, turbid fluid tinged with blood wells up; after this has been wiped away we see that the bulbar conjunctiva is chemotic, of a livid, yellowish color, and we find that the palpebral conjunctiva presents a dirty gray, opaque membrane which may be continuous, or appear only in patches. This membrane is hard to remove, and when torn away does not leave a bleeding surface, because the conjunctiva has been deprived of blood by the coagulation of an exudate which has compressed the vessels, a condition that is apt to pass into gangrene, which may invade the tarsus, or other parts of the lid and rapidly destroy the eye. <Callout type="important" title="Silver Nitrate Solution">A 2% solution should be used when there's suspicion of gonorrhea; a 1% solution is always recommended.</Callout> In very severe cases, cicatrization may cause deformity or displacement of the eyeball. This malignant form suggests diphtheria, and this diagnosis probably is correct if the patient presents evidences of diphtheria elsewhere, but it can be made positive only by a bacteriological examination, not simply of a smear, but of a culture as well, because the conjunctiva is the normal habitat of the xerosis bacillus, which looks exactly like that of diphtheria. A culture brings out identifying characteristics in a few hours, and absolute certainty is to be attained through proof that the bacilli found are able to form antitoxin. Next to the diphtheria bacillus the streptococcus probably is the microorganism most often responsible for these very grave cases. Sometimes such a membrane is to be seen in a very bad case of gonorrheal ophthalmia, and other agents are said to be guilty occasionally. <Callout type="risk" title="Gonorrhea Risk">Always use caution when dealing with potential gonorrhea infections; severe reactions can occur.</Callout> VERNAL CATARRH When a patient complains of an annually recurring irritation of his eyes with photophobia and itching, alternating from time to time with a feeling of pressure and stinging pain like that produced by a foreign body, which begins in the spring, continues during the summer, and passes away gradually as the weather becomes cool, he gives a history characteristic of the rather rare disease vernal catarrh. The secretion is slight at first, when the attack, or better the exacerbation, sets in, and increases gradually until the ordinary picture of catarrhal inflammation is presented. Sometimes the discharge is free, but it is to be found characteristically in the form of long, tenacious, transparent threads that may be removed from the transitional folds by irrigation, or with forceps. The upper lid droops so as to give a sleepy expression to the face, and when we evert it two things attract attention immediately—the peculiar, pale, bluish red, milky color of the conjunctiva, and the presence in its tarsal portion of roundish, flat, hard excrescences that may be separate, but usually are packed closely together so as to resemble the tessellated paving of a street, on account of which they are spoken of as paving stones. These excrescences never invade the transitional folds, which remain normal in color, and they are seldom if ever to be seen on the conjunctiva of the lower lids, which is simply thickened. This is the typical picture of the tarsal variety of vernal catarrh, in which no changes are to be seen about the cornea. In the bulbar form the excrescences on the tarsal conjunctiva may be few or absent, while yellowish gray, or reddish brown, semi-transparent nodules may be seen at the corneoscleral margin, where they overhang the cornea and slope away to blend with the bulbar conjunctiva. These may be found about the entire periphery of the cornea, or be confined to the region of the palpebral fissure. Their surfaces at a little distance from the cornea may appear dull and dry, and we may see near them some large, tortuous conjunctival vessels. In other cases the changes at the limbus consist of papillary elevations, a gelatinous appearing band, or a few red dots, but we are more likely to meet with these in the third, or mixed variety, in which the tarsal and bulbar forms are combined. In this mixed variety the typical changes on the lids and about the cornea may be present, or those in either location may preponderate over those in the other. Whatever the changes in the conjunctiva may be they persist almost without alteration summer and winter, whether symptoms are excited or not, and gradually undergo involution as the disease dies out. The most perfectly characteristic signs are the milky, opalescent discoloration of the conjunctiva, and the peculiar glutinous secretion, for the regular intermissions during cold weather may be omitted, or the symptoms may be at their height at this time. Nothing is known concerning the cause of vernal catarrh. It is a sporadic disease, it is not contagious, and it occurs in all classes of people. Almost always it begins in childhood or youth, attacks males more than females, and lasts an indefinite number of years until it passes away spontaneously. It is met with in adults, and some writers claim that it may start even during middle life. This disease is mistaken most often perhaps for trachoma, but it seems hardly possible for us to make such a mistake if we exercise reasonable care in making our observations, because vernal catarrh leaves the transitional folds normal, while these are the principal seat of the disease in trachoma, and the bluish, milky tinge of the conjunctiva peculiar to the former is not seen in the latter. It is possible for the two diseases to occur together in the same patient, but even then the flat paving stones of the tarsal variety of vernal catarrh do not look much like the granules of trachoma that are embedded beneath the conjunctiva on the surface of the tarsus, while the marginal excrescences of the bulbar form differ altogether from any of the trachomatous affections of the cornea. There is a certain superficial resemblance between a phlyctenule and a pericorneal nodule of vernal catarrh, yet the dissimilarity is apparent as soon as we compare the two conditions. A phlyctenule is accompanied ordinarily by other symptoms of phlyctenular conjunctivitis, in which the history is altogether different from that of vernal catarrh, while both the milky appearance of the conjunctiva, and the peculiar, stringy discharge are wanting, it develops rapidly, soon ulcerates, and is gone in a few days, while the pericorneal nodule is hard, of long duration, never breaks down, and is accompanied by the history and conjunctival appearances of vernal catarrh. The only cases in which differentiation is difficult are the rare ones in which the only prominent symptom is a single mass at the corneoscleral margin, when we may be obliged to excise it and subject it to a microscopical examination before we can decide whether it is sarcoma, an epithelioma, a tuberculoma, or an efflorescence of vernal catarrh. TRACHOMA Trachoma is a specific, contagious disease of the human conjunctiva characterized by slowly progressive changes that involve not only it, but the cornea and tarsus as well. The disease is scattered over the entire world, but is not distributed evenly; in some places it is endemic, in others it is rarely to be seen, while islets of varying size in which it abounds are to be found in regions that are free from the scourge. Wherever it is endemic it spreads slowly, infecting one person after another, yet not all. Prolonged daily contact seems to be necessary for the communication of the infection. If an individual suffering from this disease is shut up with healthy persons in an institution, some, but not all, of his associates will become infected in the course of time. If a man marries a wife who has trachoma he may become infected in less than two months, or not for several years, while part or all of his children may suffer likewise. The disease seems to be more contagious at some times than at others, but it is doubtful if it can be communicated during a brief sojourn with its victims, at least if such ordinary precautions are observed as to use exclusively one’s own towels, handkerchiefs, bed linen, and wash basins. The specific agent has not yet been determined with certainty. The early stage of the disease is marked by two characteristic features, a development of granules and a proliferation of the papillae of the conjunctiva, both of which are present in every case, though in varying proportions to each other. The papillae may be so small that they can scarcely be detected without a microscope, or so exuberant as to mask the granules. The conjunctiva is hypertrophied as the result of an infiltration of its adenoid layer, which gradually invades the subtarsal tissue and the tarsus itself, and finally is transformed into cicatricial tissue. The disease may attack the corneal epithelium at almost any stage in its course. The clinical pictures differ widely, at first because of the proportionate preponderance of granules or papillae, later according to the degree of involvement of the cornea and of the tarsus, or the extent to which cicatrization has taken place. When a patient complains of a constant irritation of his eyes, that his lids are stuck together in the morning, or that he has a more or less profuse watery or mucopurulent secretion, while his upper lids droop a little, though presenting no signs of inflammation aside from a swelling that is most marked above, we think of a possible trachoma. In our routine inspection we may or may not find the semilunar fold red and swollen, but usually see a moderate injection of the bulbar conjunctiva, especially toward the transitional folds. If the photophobia is considerable we look for a reddish film over more or less of the upper part of the cornea. After the upper lid has been everted, which is not accomplished as easily as usual, the upper transitional fold protrudes and is seen to contain spawn-like granules, 1 to 2 mm. in diameter, arranged irregularly and extending nearly from one canthus to the other. Generally they are roundish in shape, grayish in color, opaque or semitranslucent, but sometimes they are confluent and form flat or fungoid masses. If we pinch this swollen fold between our fingers a gelatinous material escapes from some of the granules, which then become flattened. Scattered over the surface of the tarsus are many little, round, yellowish, or reddish yellow spots, which are similar granules that are unable to elevate the tightly adherent conjunctiva. Like changes are present in the lower transitional fold and in the palpebral conjunctiva of the lower lid, but the granules are much less developed, a point to be considered in the differentiation from follicular conjunctivitis. The disease usually starts either in the upper transitional fold, or in the conjunctiva of the upper lid, and always is best developed in that locality. MacCallan says that the palpebral conjunctiva is the point of attack in Egyptians, among whom the transitional fold often is spared, while it ordinarily settles in this fold among Europeans. The granules may extend down into the bulbar conjunctiva, sometimes nearly to the cornea, and may involve the semilunar fold, in which the disease has been known to start. The conjunctiva usually is reddened, particularly about the bases of the granules, but sometimes it is pale; occasionally it is hard to say whether it is thickened.
Key Takeaways
- Use a 2% silver nitrate solution when there's suspicion of gonorrhea; a 1% solution is always recommended.
- Membranous conjunctivitis can be caused by various microorganisms, with diphtheria bacillus and streptococcus being common culprits.
- Vernal catarrh is a rare, non-contagious disease that causes recurring eye irritation.
Practical Tips
- Always use caution when dealing with potential gonorrhea infections; severe reactions can occur.
- For vernal catarrh, the milky appearance of the conjunctiva and stringy discharge are key signs to look for.
- In trachoma cases, granules and papillae on the conjunctiva are characteristic features.
Warnings & Risks
- Be cautious when handling severe cases of membranous conjunctivitis as they can lead to eye deformity or displacement.
- Avoid using water from bathing the body to clean the eyes; it may introduce infection.
- Properly identify trachoma by checking for granules and papillae on the conjunctiva.
Modern Application
While the specific techniques described in this chapter are historical, the principles of careful diagnosis and treatment remain relevant. Modern emergency responders can apply these diagnostic methods to quickly identify and manage eye infections, ensuring prompt care that could prevent long-term complications.
Frequently Asked Questions
Q: What is the recommended solution for treating suspected gonorrhea conjunctivitis?
A 2% silver nitrate solution should be used when there's suspicion of gonorrhea; a 1% solution is always recommended, even if no suspicion exists.
Q: How can one differentiate between vernal catarrh and trachoma?
Vernal catarrh leaves the transitional folds normal while trachoma involves them. Vernal catarrh also presents with a milky appearance of the conjunctiva, which is not seen in trachoma.
Q: What are some common symptoms of membranous conjunctivitis?
Symptoms include swelling and redness of the lids, formation of a grayish membrane on the inner surface of the lids, and increased bleeding when the membranes are removed. Severe cases may lead to gangrene or eye deformity.