CHAPTER X Tue Iris (Part 4)

had gonorrhea and is suffering from rheumatic pains in his joints, the iritis is quite apt to prove to be gonorrheal; if he has other symptoms of tuberculosis we may be able to prove this to be the cause through a local reaction to tuber- culin. The cause of an iritis may be said to be evident also when it complicates an acute infectious disease, a wound or inflammation of the eye, and to be extremely probable when it sets in some weeks after a wound of the other eye. No one can differentiate the cause of an iritis from the appearance of the iris, yet occasionally we are able to get some help from an inspection. Sometimes we can see with the aid of a magnifying glass and oblique illumination that the iris seems to be scarcely swollen at all, but shows on its surface red lines, which are blood vessels, together with a grayish deposit of fibrin, perhaps with minute threads floating out from it, which renders the design indistinct, while one or more parts of the dark edge of the pupil appear to be glued to the anterior capsule so as to form curved, linear posterior synechie, which are largest and strongest below, with their con- cavities toward the center of the pupil. In another case the whole iris seems to be swollen and the posterior synechie are pointed or an- gular projections with broad bases into the pupil. It is not very often that we see a case of iritis which presents such characteristics typically, but when we do we are able to draw a distinct inference 224 DIAGNOSIS FROM OCULAR SYMPTOMS as to the nature of the inflammation. In the first case the surface of the iris is the part mainly affected, and the synechie have been formed by the settling of fibrin between the contiguous surfaces of the iris and lens; in the second the entire tissue of the iris is involved and the synechie have been formed by exudates from focal points of inflammation in the parenchyma of the iris. This differentiation can be made only in a certain number of cases, and, as a rule, only in the first attack of the disease, not only because there are many inter- mediate grades between the two conditions which modify the clini- cal appearance, but also because repeated attacks change the picture so much that a clear distinction is impossible. When it can be made it affords a little help toward determining the probable cause, since a superficial iritis seems to be met with chiefly in connection with those diseases and inflammations which are apt to excite rheumatic pains and formerly were grouped together as rheumatic, while a parenchymatous iritis suggests instead a disease that is known to create foci of inflammation in tissues, such as syphilis or tubercu- losis. In some cases of syphilitic and tuberculous iritis these foci in the iris become large enough to form visible local elevations, and are then of great help in making the diagnosis. Secondary Iritis It would seem as though an iritis which accompanied an ulcer of the cornea, or an acute conjunctivitis, would be recognized im- mediately as secondary, but my attention has been called more than once to its presence as an evidence of syphilis by practitioners of good ability, whose care was proved by the fact that they observed the condition, so it may be well to emphasize the fact that when an iritis develops in an eye which is inflamed in any other part, or con- tains a tumor, the probability is that it is secondary, and does not depend on any general disease. Of course it is possible for an iritis to develop from some other cause in an eye which is otherwise in- flamed, but this does not happen very often. When it is secondary to a conjunctivitis or keratitis we ascribe it commonly to the effect of toxines which have penetrated the capsule of the globe, diffused through the aqueous, and attacked the iris, but the inflammation may spread to the iris by contiguity from some other portion of the uvea, or from the sclera, or may be set up by the presence of a tumor, which seems to act in such a case like any other foreign body. THE IRIS - no Traumatic Iritis, Cyclitis, and Iridocyclitis An iritis may result from a wound of the iris made either by acci- dent or design, or from an injury to the cornea or the lens, is plastic, as a rule, and may be of any degree of severity according to the nature of the injury. When the ciliary body is wounded the in- flammation may be either plastic or serous at first, and be of any degree of severity between the two following extremes. If the wound is followed by intense pain in the head, vomiting, fever, cedema of the lids, chemosis of the conjunctiva which fails to con- ceal a very pronounced ciliary injection, tenderness of the eyeball, and by the formation of exudates behind the iris, in the pupil, in the vitreous, and in the ciliary body itself, a severe plastic iridocyclitis has started which will probably cause a complicated cataract and phthisis bulbi by cutting off the nutrition of the eye. In some of these cases the pupil will be found to be dilated because of the pre- ponderance of the cyclitis over the iritis and the contraction of exudates in the ciliary body. If pus appears in the anterior cham- ber sepsis is present, and we are dealing with a purulent cyclitis which soon will develop into a panophthalmitis. The other extreme is seen when a wound of the ciliary body seems to heal kindly, but the eye continues to maintain a little tenderness over the ciliary region and a tendency to be irritable, that is, to be- come injected, to lacrimate, and to show some photophobia on slight provocation. The danger of sympathetic ophthalmia is just as great in these cases as in the preceding, if not even greater because of the difficulty met with in trying to convince patients of the risk they are running. The danger of sympathetic ophthalmia is great in all cases of wound of the ciliary body, though occasionally we meet with a person who has carried such a wounded, irritable eye for many years without losing the other. Iritis Met With in Acute Infectious Diseases An iritis may occur in the course of any of these diseases, and is supposed commonly to be caused by metastasis of the characteristic microorganism. Typhoid bacilli have been found in the iris in typhoid fever, pneumococci in cases of pneumonia, and bacteria coli in those of enteritis, and sometimes it seems to be excited by the filarie circulating in the blood of a person suffering from malarial 226 DIAGNOSIS FROM OCULAR SYMPTOMS poisoning. In other diseases it may perhaps be caused by toxines, for no influenza bacilli have been found in any case of influenzal iritis. Such cases as these are rare, and are recognized easily. Syphilitic Iritis When a patient presents the typical symptoms of an iridocyclitis in one eye, that is, a swollen upper lid, an extensive, dark, ciliary injection, dustlike deposits on Descemet’s membrane, a discolored iris with blurred details, and posterior synechie, our first thought is apt to be of syphilis, especially when he is young. It may be possible for syphilis to excite a superficial iritis. Evi- dence to this effect can be drawn perhaps from the rare cases de- scribed by Roemer, in which a very early roseola, associated some- times with a superficial papule, has been observed on the iris about six weeks after infection. Reddish spots appear on the ciliary zone, caused by congeries of blood vessels, possibly with minute, bright red nodules, and soon disappear spontaneously. Perhaps the reason why they are not seen oftener is that they cause no trouble and soon disappear. Roemer also says that Krueckmann has called atten- tion to a condition in secondary syphilis in which whitish spots ap- pear on the ciliary zone, especially about the crypts, in which the deep vessels look like white branches, with no preceding iritis. But clinical experience leads us to believe that such a superficial syphilitic iritis is exceptional. In the majority of cases of syphilitic iritis we find the iris more or less thick and oedematous, with posterior synechie that are den- tate, yet sometimes mixed with linear ones, and a hyphema, or a jellylike exudate, often is present in the anterior chamber, but none of these conditions are diagnostic of syphilis. The only cases in which a diagnosis of syphilitic iritis can be made with any approach to certainty from the appearance of the iris are those of the papular form, which will be described presently. We must rely on the his- tory and the presence of other clinical evidence of the disease. A positive Wassermann alone is not conclusive evidence as to the nature of the lesion, for other causes are competent to excite an iritis in a person infected with syphilis. An iritis may be the first secondary symptom and appear about six weeks after the initial lesion of syphilis, but this is unusual. In such a case the presence of a chancre will suffice for the diagnosis, THE IRIS 227 but if this cannot be demonstrated we shall be obliged to await the onset of the other secondaries, which will appear in a few days. In the majority of cases iritis is one of the late secondary manifes- tations of the disease, and comes on between the third and the twelfth month after infection, when the presence of a characteristic cutaneous eruption, of mucous patches in the mouth, or of hard, painless, enlarged lymphatic glands, render the diagnosis easy. Sometimes it occurs during the second year, after the other secon- daries have disappeared, and then we have to rely on the history, a positive Wassermann, and the exclusion of all other conditions that ordinarily excite this trouble. Iritis occurs in only a small percent- age of the persons who acquire syphilis and is looked upon by some authorities as an indication that the disease is more than usually grave. This gravity seems to be increased when it assumes the papu- lar form. The best of treatment may not be able to prevent the outbreak of this inflammation, which has been known to appear after treatment had been discontinued because the patient was apparently well. In such cases other causes must be rigidly excluded. Only one eye is affected in the majority, but in a large minority the second eye is attacked after an interval. NRelapses are common and may occur in each organ alternately. A thorough examination of the eye is likely to reveal an involvement of many other tissues. Sometimes a deep opacity can be seen in the cornea near its periphery, which re- sembles an interstitial keratitis, and then we shall probably find the underlying portion of the iris to be more swollen than the rest. The papilla often is hyperemic, and sometimes is the seat of an optic neuritis. The retina may be inflamed primarily or secondarily, or we may see signs of choroiditis. The vision may be reduced to scarcely more than perception of light by the cloudy vitreous when the choroid is involved, and yet be regained almost perfectly under energetic antisyphilitic treatment. The prognosis of the purely fibrinous form is pretty good under energetic treatment, though relapses cannot be guarded against, and the vision remains impaired more or less in a great many cases. Each relapse in every form of iritis increases the number of posterior syne- chiz, and this increase may lead to exclusion and occlusion of the pupil, especially when the disease is neglected. The result of this may be crater pupil, atrophy of the iris, secondary glaucoma, com- plicated cataract, and phthisis bulbi. | 228 DIAGNOSIS FROM OCULAR SYMPTOMS The Papular Form of Syphilitic Iritis When we see an iritis with little hyperemic nodes in the region of the sphincter we may be practically certain that we are dealing with a syphilitic manifestation, but we must always confirm this sug- gestion by other evidence of the presence of this disease. ‘The nodes often are called gummata, but a better name is papules because it is expressive of their nature, which differs from that of gummata. Their appearance when the attack of iritis occurs early in the second- ary stage of syphilis differs considerably from that seen in late at- tacks, so we distinguish between early and late papules, though no sharp line of demarcation can be drawn between them as we meet with many transitional forms. Early papules are small, quite red, apt to be more numerous than the late, and are to be observed more frequently. They may form a red ring about the pupil, though they seldom exceed six in number. The nodular condition of this red ring serves to distinguish it from the uniform or finely striated redness of the region of the sphincter sometimes seen in an iritis secondary to a serpiginous ulcer of the cornea, or due to pneumococcal infections of the interior of the eye. When the cedema of the iris is very great, even large papules may be buried in it and manifest themselves only as an irregular swelling at the margin of the pupil. The less fluid there is in the exudate, the more prominent they become. Late papules may be single, are usually few when multiple, are larger than the early ones, are grayish or yellowish because the hyperemia is less, have smooth surfaces, and sometimes look as though they were rather dry, especially when oedema is absent. The later they are the larger and more solid they appear to be. Rarely they have been known to extend out beyond the minor circle into the ciliary zone, when we are apt to find several confined to one sector of the iris, the largest ones at the periphery, where they indicate a similar affection of the ciliary body, the smallest at the pupillary mar- gin. This is the group syphilide. These late papules perhaps may form an intermediate stage toward the formation of gummata, for sometimes, even with the microscope, we are unable to determine whether one of them is or is not a gumma, and true gummata are said to have appeared in the iris during the secondary stage of malignant syphilis. All of these papules originate in the stroma of the iris and may grow rapidly or slowly. The rapidity with which they may increase THE IRIS 229 in size is shown by the fact that a rapidly growing, cellular papule has been taken for a hemorrhagic infarction. A papule of this kind may rupture and produce a hyphema in which a yellow zone perhaps may be seen. The response to treatment is not always the same. Early papules become absorbed and may leave either no traces, or atrophic spots in the sphincter. The involution of a late one frequently begins with a central softening and the papule flattens as absorption proceeds, or it may rupture and evacuate its contents into the anterior cham- ber; in the latter case we may see the node replaced by a little red mass of granulation tissue. _After these papules have disappeared they leave spots that mark not only the injury that has been in- flicted on the stroma and the chromatophores, but also atrophy of the muscular tissue of the sphincter, and remain permanently as characteristic signs that the patient has suffered from this form of iritis. The prognosis of the papular form is not as good as that of simple fibrinous syphilitic iritis. Histological research seems to show that the papules are far more common than they appear to be clinically, that in most cases they are too small to be visible, and that an increase in their size seems to indicate an increase in the seriousness of the condition. Roemer states that statistics have shown one half of the eyes thus diseased to become blind. FPara- syphilitic diseases of the central nervous system, tabes and general paresis, have been observed to appear later in many cases. Syphilitic papules may be distinguished from the rare vascular and other tumors of the iris by the violent iritis with which they are associated, as tumors of the same size seldom cause any irrita- tion. They may be differentiated from tuberculous nodules by their preponderance in the pupillary zone, the reddish color of the early ones, the absence of a local reaction to tuberculin, the presence of a positive Wassermann, as well as of other clinical signs of syphilis, and their response to antiluetic treatment. The iritic nodules of leprosy are attended by other symptoms of that disease, are found in the peripheral portion of the iris as a rule, and usually the iritis is chronic. The nodules of ophthalmia nodosa are asso- ciated with the characteristic symptoms of this disease in the con- junctiva. 230 DIAGNOSIS FROM OCULAR SYMPTOMS Gummatous Iritis This variety of syphilitic iritis is met with very seldom. A single, large, yellow tumor may be seen to lie in the iris of one eye near its ciliary margin with the surface about it lying in folds, to be recognized at once as a tumor that has started in the ciliary body and has pushed its way through the iris. It may be a gumma, a solitary tubercle, or a sarcoma, and often the clinical differentia- tion is difficult. If the growth is attended by a severe iritis, other signs of tertiary syphilis, a positive Wassermann, and it is in- fluenced by antisyphilitic treatment, the diagnosis of a gumma may be considered positive. If the Wassermann is negative, and a local reaction is obtained from a subcutaneous injection of tuberculin, it is a tubercle, but a tubercle is not