CHAPTER X Tue Iris (Part 5)

excluded by a positive Wasser- mann; we may have to decide from the preponderance of the symp- toms of tertiary syphilis and of tuberculosis, or depend on the effect of treatment for our diagnosis. A sarcoma usually is darker and more vascular than either of the others, grows slowly, and excites no inflammation until it is quite large. It is still more uncommon than a gumma or a tubercle, and is not affected by any medical treatment. Probably a gumma of the iris starts in all cases from the ciliary body. Its appearance may or may not be preceded by a plastic iritis. It may break down and form a hypopyon, or an opacity may form in the corresponding place in the cornea, which later may be perforated by the growth. Descemet’s membrane always is studded with deposits. Cataract and secondary glaucoma are frequent com- plications. In other cases a gumma of the ciliary body forms a bluish black protrusion of the sclera and perforates at that point. The prognosis is bad. The eye is lost in most cases, and when it is saved the vision is likely to be much impaired. Sometimes the involution of a gumma has been known to leave an aperture in the iris. Tuberculosis of the Iris Modern research has taught us that tuberculosis of the iris may appear in many atypical forms, so when the etiology of an iritis is at all obscure, especially in a young person, we should test at once with tuberculin. Calmette’s instillation of a solution into the conjunctival sac should never be made, for fear of disastrous results. Von Pirquet’s test leaves us still in doubt as to the nature of the THE IRIS 231 lesion, though, if the test is made perfectly, a negative result is a pretty good sign that there is no tuberculosis in the organism. The subcutaneous injection is the best method, for if it should excite a local reaction in the eye, whether it was associated or not with a general one, we should be fairly safe in concluding the iritis to be tuberculous, even though it presented no characteristic clinical symptoms. When we see a number of minute, grayish yellow nodules, which vary in size from that of a pinpoint to that of a pinhead, scattered irregularly over the surface of an inflamed iris, confined mainly to the ciliary zone, but with perhaps a few small ones in the pupillary, we have reason to feel confident that the inflammation is tuberculous. The iritis is parenchymatous, as is shown by the oedematous ap- pearance of the iris and the dentate posterior synechie. We suspect its nature to be tuberculous when we see a slow, chronic iritis in which the entire iris is swollen, but presenting irregu- lar lumps scattered over it as though the cedema was not uniform, though no nodules can be seen. These cases are complicated fre- quently by a crater pupil, and we must investigate the other eye carefully to make sure that it has not received a wound in order to exclude sympathetic ophthalmia, which often presents a similar picture. When a single yellowish tumor is seen at the ciliary margin of the iris we suspect it to be a solitary tubercle if the patient is young, if its surface is rough and if it is accompanied by much fibrino- purulent exudate, while if the patient is older and is syphilitic, it is more likely to be a gumma. The differentiation in doubtful cases, and from sarcoma, has been given under gummatous iritis. Tuberculous iritis occurs chiefly in young people and rarely is a complication of pulmonary or joint tuberculosis. In the majority of cases it appears to be secondary to disease of the lymphatic glands, especially those of the mediastinum and mesentery. Atten- tion recently has been called to a chronic form that is said to attack young girls, and also women at the period of the climacteric, who seem to be otherwise in perfect health. Gonorrheal Iritis When a patient, particularly if he is a young man, suffers from an iritis and a simultaneous attack of articular rheumatism, it is 232 DIAGNOSIS FROM OCULAR SYMPTOMS well to investigate for gonorrhea. Iritis rarely occurs during the acute stage of this disease, but is a rather common accompaniment of gonorrheal rheumatism, which attacks the joints during the late stages, or after the discharge has ceased. It is apt to be of the superficial type, and we often see at first a grayish exudate, com- posed of coagulated fibrin, at the bottom of the anterior chamber, which is not diagnostic, but is very suggestive of this cause. Dernehl has reported some cases that seem to show that the only accompany- ing sign from which we can make the diagnosis may be a chronic prostatitis, and that repeated milkings of the prostate may be necessary to find Gram negative diplococci. This form of iritis is not only obstinate, but relapses are apt to be very frequent. Both eyes commonly are affected, though it may be alternately and at intervals. Exclusion of the pupil is not so very rare, and the iris may become atrophic in old cases. Total posterior synechia is seen sometimes. The iris alone may be af- fected at first, then the disease may spread to the ciliary body and the vision be impaired not only by the deposits of fibrin, the pos- terior synechiew, and the pigmented spots left on the anterior cap- sule by their rupture, but also by the formation of dustlike opacities in the vitreous. For some reason with which we are not acquainted the choroid seldom is attacked. We suppose the origin of this form of iritis to be metastatic, and that the gonococci give rise to toxic substances which maintain the inflammation for a long time, although they themselves are unable to live long in this tissue. Gouty Iritis When an elderly patient who is subject to gout is seized suddenly with intense pain in both eyes during the night, simultaneously with a typical attack of pain in the affected joint or joints, the chances are that he has an attack of gouty iritis. In the majority of cases we find both eyes very red from a conjunctival congestion that may mask the episcleral, deposits on Descemet’s membrane, some dis- coloration and obscuration of the iris, and a few small posterior synechie; but in other cases these symptoms are not so marked, only one eye may be affected at a time, its onset may not be coincident with acute trouble in the joints, and sometimes the diagnosis can- not be made until a subsequent attack of gout renders it clear. THE IRIS 233 Possibly we should include under this heading the iritis that is said to appear occasionally in the children of gouty parents, and is con- sidered to have a rather bad prognosis. Rheumatic Iritis When a patient complains of photophobia and lacrimation of one eye, which presents a congestion of the conjunctiva, or perhaps a slight conjunctivitis, has a normal pupil and shows no recognizable signs of iritis, the most skillful diagnostician may make a mistake, and probably has done so many a time, for these may be the first symptoms of a superficial iritis that develops slowly. After a few days we see a ciliary injection, a few vessels on the surface of the iris, and a tendency on the part of the pupil to contract, or perhaps to dilate slightly. It is well for the patient if we have suspected the true nature of the disease and instilled a mydriatic, but we are apt to hesitate to do this because most of the patients are elderly and we fear to excite a glaucoma. Usually we wait until the details of the iris are blurred by a deposit of fibrin, and then we are likely to find the characteristic linear synechie of a superficial iritis. Some- times the entire iris and pupil are covered by a layer of fibrin which is stripped off by the dilatation of the pupil. This rather unusual onset of an iritis is described under the head- ing of rheumatic iritis because it is met with almost if not quite wholly in the class of cases that formerly were included under this name, but it can no longer be considered to indicate rheumatism as its cause. It is simply one of the ways in which a superficial iritis may develop. In most cases the inflammation sets in rapidly with pain and the distinctive symptoms of iritis already described. It is not uncommon for us to obtain a history of acute or chronic articular rheumatism, or at least one of indefinite pains in the joints or muscles, particularly in elderly people, but we must not accept these as necessarily indicative of the etiology. All infections or localized foci of suppuration must first be excluded, and the diag- nosis of rheumatism be confirmed by the finding of an excess of uric acid in the urine, before it can be taken into account as a pos- sible cause. Still after everything else has been excluded a small number of patients remain in whom we can detect no other cause than a uric acid diathesis, and these we may perhaps term rheumatic, 234 DIAGNOSIS FROM OCULAR SYMPTOMS whether the patients have rheumatic pains or not. The following case may be of interest as illustrative of this type. A lady over 60 years old, a grandmother, was seized suddenly with pain in one eye, which presented the typical symptoms of a superficial iritis when seen a few days later. She was well nour- ished, in excellent general health, and asserted positively that she had never had a sore throat, a toothache, any rheumatic pains or twinges, or any other ache or pain in her life, aside from those incident to childbearing, until this trouble in her eye. Investigation revealed no signs of syphilis, tuberculosis, or any other disease, and nothing to direct attention to any focal point of infection, but her urine was found to be overloaded with uric acid and urates. After the excess of uric acid had been reduced somewhat by antirheumatic treatment the inflammation subsided. The treatment was _ perse- vered in for a long time after the iritis was well, until the excess of uric acid had been largely done away with; no relapse has taken place at the end of more than three years, and during this time she has developed no trouble which might suggest that a focus of septic inflammation had been overlooked. The uric acid diathesis com- monly is associated with rheumatic pains, even though it was not in this case, so it seems reasonable to conclude that the diagnosis of rheumatic iritis, based on the excess of uric acid in the urine, was correct, Rheumatic iritis never is purulent, and is not likely to result in atrophy of the iris. A slight attack may last only a few days, but one of ordinary severity is apt to persist for a number of weeks. Relapses are common. Iritis from Anzmia ‘When the patient has no disease to which the iritis can be attrib- uted, and the urine shows no excess of uric acid, it may be well to take into account the condition of the blood. Anamia seemed to be the cause in a young man who had a very obstinate iritis asso- ciated with a diabetes insipidus, but with no history or symptoms of any disease known to produce such an inflammation. Examination of the blood revealed nothing except a simple anemia, that of the urine nothing aside from the polyuria. Various lines of treatment were tried with no effect until finally iron alone was prescribed, when the iritis and the diabetes insipidus progressed rapidly and with equal steps to recovery. THE IRIS 235 Purulent Iritis The iritis that accompanies an ulcer of the cornea, which has not perforated, often is associated with a hypopyon, the pus of which is free from bacteria and absolutely sterile. This may be called an aseptic purulent iritis. It is induced by the toxines of the micro- organisms present in the ulcer, which have become diffused through the posterior layers of the cornea and the aqueous and have excited an exudation of leucocytes from the iris. An aseptic purulent iritis rarely is excited by a general disease, though sometimes a periodic iritis with hypopyon is met with in malaria, a similar iritis with hypopyon occasionally is excited by influenza, and sometimes one ap- pears as a symptom of an existing diabetes. It is a good rule to examine the urine for sugar whenever we meet with an iritis with hypopyon that is not associated with a corneal ulcer, or with an inflammation of some other part of the eye, and does not occur in the course of an infectious disease. The pupil may be occluded for a time by an exudate in diabetes, but a peculiarity of this exudate is that, as a rule, it is soon absorbed. Cases have been reported in which iritis occurred in diabetes without any hypopyon and with the formation of posterior synechie, but they are of even rarer occurrence than the others. Septic purulent iritis generally follows a wound, or the perfora- tion of a corneal ulcer, through which pyogenic organisms have gained access to the iris. Rarely it is brought about by metastasis in septicemia and pyzemia, as well as in various bacterial diseases. Pneumococci have been demonstrated in iritis accompanying pneu- monia, typhoid bacilli in one with typhoid fever, bacteria coli in one due to enteric trouble. Sometimes in these diseases the iritis is superficial with simply a hypopyon to show its purulent nature, in others the tissue of the iris is permeated and given a yellowish or brassy color. The prognosis depends on the virulence of the micro- organisms and the power of resistance of the tissues; it is good in mild cases, not so good when the inflammation is severe but con- fined to the anterior segment of the globe, as the vision then is badly impaired quite often, and bad when it extends back into the posterior segment, as it is then apt to go on to panophthalmitis. 236 DIAGNOSIS FROM OCULAR SYMPTOMS ATROPHY OF THE IRIS When we see in an uninflamed eye an iris that has lost its luster and the details of its design, so that it looks dull and bleached, and we can see the vessels stand out in it like cords, or perhaps like reddish lines, we know that it is atrophic. The stroma may have disappeared to such a degree that we can see the pigment of the retinal layer, or this layer also may be so thin that we can obtain through it a reddish reflex from the fundus with the ophthalmoscope. Sometimes apertures are to be seen where the entire tissue has given way, and the margin of the pupil is apt to be frayed. Such an atrophy may affect the entire iris, or only a portion of it, and always is due to some lesion that impairs the nutrition. Partial atrophies are found mostly in the region of the sphincter about synechizx, sometimes elsewhere, as when left by the involution of a tubercle or a gumma, or caused by an iridodialysis. A senile atrophy occa- sionally appears in old people as the result of arteriosclerosis with no preceding inflammation, but much more commonly an atrophic con- dition can be traced to a chronic iritis, to repeated attacks of acute iritis, or to glaucoma. Not infrequently atrophy is caused by the constant stretching incident upon an adherent leucoma. In rare cases it is associated with a yellowish color, siderosis, and is then indicative of the presence of a piece of iron or steel in the eye. ‘TUMORS OF THE IRIS A new growth presents itself as a rounded swelling that projects from the surface of the iris into the anterior chamber. If it is quite small we observe whether it is accompanied by iritis or not, for if it is we probably have to deal with a papular or a tubercular iritis, possibly with the lymphomata met with in leucocythemia or pseudo- leucocythemia, or the nodules of leprosy. The differentiation of the first two has been given already, lymphomata are recognized through the symptoms of the fundamental disease and an examina- tion of the blood, leprous nodules by the presence of other symptoms of leprosy. When no iritis is present we notice the color and the general ap- pearance of the growth. If it is almost transparent it is a small serous cyst, which may be congenital, but in most cases has resulted THE IRIS 237 from a wound of the eye; when it has the luster of mother of pearl it is a pearl cyst, which always is traumatic in its origin and is usu- ally due to the implantation of an eyelash into the iris; when it is grayish or yellowish we have to think of a possible congenital der- moid, and of the very rare entozoal cysts produced by filarie and cysticerci. The last may be diagnosed if we can see within the cyst a whitish body that changes its shape from time to time. If the little tumor is dark it may be a congenital pigmented nevus, or a commencing sarcoma; the differentiation between these can be made only after prolonged observation, as the nevus will not increase in size, though it may become darker, while the sarcoma will grow slowly. A large tumor almost always excites iritis, is accompanied by pain, causes an opacity of the cornea wherever it comes in contact with its posterior surface, and produces secondary glaucoma me- chanically. A cyst is recognized through its more or less transparent walls, and its transparent or translucent contents. It is very ex- ceptional for the wall to rupture and the cyst to