CHAPTER VII THE CONJUNCTIVA (Part 7)

in the case of a chancre until the disease has become diffused through the system, when the secondary symptoms appear. Mucous patches like those seen in the mouth occur on the con- junctiva during the secondary stage of syphilis, or papules may ap- pear on the bulbar portion, the caruncle, or the semilunar fold, and leave brownish spots when they heal. The descriptions given of a gumma of the conjunctiva do not quite agree. Ball says that they are rapidly growing, rounded, smooth, firm tumors of a light pink color and the size of a split pea, which cause no pain when not complicated, and quotes De Beck as saying that they “usually are developed in the ridge where the con- junctiva passes into the cornea, but may occur in other parts of the membrane.” Roemer says that their general color is a dull red with yellowish gray on the top and margins, and that they excite much irritation of the eye, into which they extend deeply, while serious ulcerations are apt to take place. Probably both authors are right as regards individual cases, but it is doubtful if a diagnosis can be made with certainty except by the observation of the effect of treatment, or by an examination of excised tissue. A Wassermann test should be positive, but this would not exclude the development of some other form of tumor in a syphilitic, and a gumma would not be excluded absolutely by a negative result. CONJUNCTIVA 153 AMYLOID AND HYALINE DEGENERATIONS OF THE CONJUNCTIVA These conditions are very rare in the United States. The lids gradually grow thick and heavy until the patient can no longer open his eyes and he presents extreme ptosis with no external signs of inflammation. The lids are stiff, hard to separate, still more difficult to evert. The bulbar conjunctiva may appear to be normal or wax- like; the cornea usually is clear. On eversion of the lids we find that their entire conjunctive have been changed into a swollen, smooth, friable, waxy mass, which bleeds very little when torn, with some elevations perhaps toward the transitional folds. We are unable to tell whether this is an amyloid or a hyaline degeneration of the conjunctiva except by excising a piece of the tissue and ascertaining its chemical reaction, for the two conditions resemble each other in every other respect. Such a degeneration is met with only in adults, and may be unilateral or bilateral. Some of the patients have had trachoma, and in these the cornea may have suffered, but there seems to be no etiological connection between these degenerations and this disease. It is said that the process may go on to calcification or ossification of the conjunctiva. CALCIFICATION OF THE CONJUNCTIVA Leber described in 1898 an extremely rare disease or degeneration that he called conjunctivitis petrificans. During an attack of con- junctivitis white spots appear in the palpebral conjunctiva, and the epithelium over the larger ones is cast off, laying bare hard masses of lime, probably in organic combination with a base consisting of degenerated connective tissue. More attacks follow and more lime is deposited during a period of months or years, until a large amount is present. S'aemisch removed 2 ccm. from one patient who had suffered three attacks. The cause is unknown. While the deposit of such large quantities of lime in the con- junctiva is one of the greatest of rarities, that of small quantities is common. We see little yellowish deposits scattered irregularly over the palpebral conjunctiva, or in the folds, each the center of a little spot of hyperemia, where they may be either the cause or the result of a chronic inflammation, but much more often they are to be 154 DIAGNOSIS FROM OCULAR SYMPTOMS found in the acini of the Meibomian glands, where usually they are symptomatic of the uric acid diathesis; this is commonly called lithiasis of the conjunctiva. The patients complain of a scratchy feeling, like that produced by a foreign body, and are subject to a chronic conjunctivitis which cannot be cured until these small masses of lime, uric acid, or sodium urate, have been removed. LEPROSY OF THE CONJUNCTIVA One or more nodules on the conjunctiva associated with an ab- normal whiteness or loss of the eyebrows or lashes, infiltrated or nodular lids, and perhaps similar nodules in the cornea and iris, are quite suggestive of leprosy. The diagnosis is made by finding leprosy bacilli in a nodule, or in the juice obtained from an incision into an infiltrated place in the lid. An interstitial keratitis with iritis is said to be not uncommon, and sometimes multiple, rarely single, nodules appear in the iris and partially fill the anterior chamber. BURNS OF THE CONJUNCTIVA The diagnosis of a severe burn of the eye is easy. The history of an accidental introduction of lime or other caustic, molten metal, hot fat, hot water, or steam, into the eye usually is quite definite; the swollen lids and the chemosis testify to its severity. We may find lime or metal present, or see grayish white patches where the conjunctiva has been burned to form eschars, which later are cast off so as to leave raw surfaces which cicatrize and agglutinate to form symblepharons. More superficial burns produced by milder caustics, like carbolic acid, acrid vapors or liquids, and the flash of electric light from a short circuit, or electric welding, or by prolonged exposure to a powerful electric light, excite an acute conjunctivitis of short dura- tion, but accompanied by severe pain, photophobia, lacrimation, red- dening of the conjunctiva, sometimes chemosis and cedema of the lids. An exactly similar picture is seen in snow blindness, which is caused by the reflection of the sun’s rays from snow that induces a loss of the corneal epithelium. All degrees between these two extremes are met with. In the first certain areas of conjunctiva are permanently destroyed, in the other the injury seems to be limited to the epithelium, just as in CONJUNCTIVA 155 burns of the skin. The prognosis in burns with acids and alkalies generally is in accordance with the nature of the agent, yet quick attention may be remarkably efficient in limiting the effects even of the worst, while mild ones may produce untoward results. Quick lime is extremely destructive, yet immediate proper treatment may cause it to result in nothing worse than pain and inconvenience for a few days. Carbolic acid generally effects only a trifling and tem- porary injury, yet I have known an eye to be permanently blinded after a bath of it, and at the same time have seen nothing worse than a very superficial burn produced by nitric acid, and by a solu- tion of caustic potash, in cases in which proper treatment had been applied immediately.