Complete Text (Part 6)

the temporal edge. 2. Color of disc normal, except THE central excavated POR- TION, which is white or gray. 3. Blood-vessels bend over the edge of the excavation. Myopic Crescent. Disc Partially Excavated. (Ladle-shape.) 1. The choroid on the temporal EDGE OF DISC IS ATROPHIED, EXPOSING THE SHINING WHITE SCLEROTIC. If the atrophy extends and loses its crescent shape it is called a post, staphyhvia, 2. Color of disc normal, except ON TEMPORAL EDGE, which is shining white, and not infre- quently pigmented. 3. The larger blood-vessels may appear to be driven in under THE nasal half OF THE DISC. FOREIGN BODIES IN THE EYE. 73 Foreign Bodies on ConjimctiTa. I. Painful. Treatment, Cocaine ; evert lids and remove. Bums with lime, melted metals, etc., should be carefully washed, and all particles removed; oil and atropine instilled. Foreign Bodies in Ant. Chamber and Iris. 1. Often painless. 2. Seen by oblique light. Treatment, Open ant. chamber and remove with magnet, or forceps ; or it may be advisable to remove that portion of the iris on which it rests (iridectomy), Foreig^n Bodies in the Vitreous. I. A suppurative process of the vitre- ous follows, and is accompanied by a general inflammation of the whole eyeball (panophthal- mitis) ^ which terminates when the eyeball is destroyed, the eye blind, and the globe atrophied (phthisis bulbi). Treatment, Remove with magnet if possible. Enucleation may be necessary to avoid sympathetic inflammation. Cysticercus. I. May be found in the anterior chamber or vitreoos. Foreign Bodies on Cornea. I. Very painful. Treatment, Cocaine ; remove with a sharp- pointed instrument without abrasion of corneal epithelium. Foreign Bodies in Crystalline Lens. 1. Usually painless. 2. Rarely seen on account of the opacity of lens (traumatic cat.). Treatment is determined by the amount of opacity and inflammation following. If lens should swell and be painful, extraction is indicated. Foreign Bodies Back of the Vitreous. I. May be in the retina, choroid, sclerotic, optic nerve or orbit. They may set up suppurative inflammation or become en- capsulated. Treatment, Enucleation will depend on s]rmp- toms in each individual case. Filari. I. May be found in the eyelids. 74 DISEASES OF THE LIDS. Special Surgical. General Surgical. Stye Chalazion Entropion Ectropion Symblepharon Ankyloblepharon Trichiasis (see page 76). Papillomata. • ' 76 Epithelioma. " 76 " 76 Gumma. 77 " 77 Chancre. 75 Distichiasis " 75 Bums. Ptosis 77 Xanthelasma 77 Treatment, General surgical principles. DISEASE OF THE ORBIT. General Surgical. Foreign bodies. Tumors, malignant and non-malignant. Cysts. Cellulitis. Abscess. Periostitis. Exostosis. Fractures. Enchondroma. Emphysema. Angiomata. Aneurism. Cysticerci. Treatment, General surgical principles. DISEASES OF THE LIDS (Continued). 75 Blepharitis Marginaiis. I. Small fine crusts or scales ALONG THE EDGES OF THE UDS'; EASILY DETACHED, AND DO NOT LEAVE A BLEEDING SURFACE. 2. No ULCERATION AT ROOTS OF LASHES. 3. Edges of lids reddened. 4. Lashes are not destroyed by long- continued inflammation. 5. Trichiasis does not follow as a re- sult of b. marginaiis. Treatnunt. Correct error of refraction. Blepharitis Ciliaris. 1. Large crusts or scales often MATTING OR GLUEING TWO OR MORE lashes TOGETHER ; when these are detached the lashes are usually pulled out, and a bleeding surface remains. 2. Ulceration at roots of lashes. 3. Edges of lids red and occasionally swelled. 4. Lashes are destroyed if disease is not checked ; the lids become bald (madarosis), 5. Trichiasis follows as a result of b. ciliaris. Treatment, Ung. hg. ox. fla. (gr. xii. vaseline I i.) rubbed into edge of lids at night. Trichiasis. I. Tendency of the individual lashes to grow inwards, and rub on the eyeball. Treatment, Epilation. Cautery to roots of intuming lashes. Distichiasis. I. There are two rows of lashes, and the inner row turns in towards the eyeball. Treatment. Operation. 76 DISEASES OF THE LIDS (Continued). Stye (Hordeolum). 1. Acute active process. 2. Painful. 3. Inflamed gland or hair follicle, or small abscess near margin of eyelid. 4. Pus FORMS. 5. Integument involved. 6. Duration a fev^ days. Treatment. Attention to the general health. Hot fomentation. Incision. Correct, any error of refraction. Chalazion. I. Chronic slow process. 2. No PAIN. 3. An enlarged meibomian gland, due to obstructed duct, and dilatation by its own secretion. 4. No PUS, but secretion undergoes changes. 5. Integument not usually involved. 6. Duration weeks. Treatment. Operation. Open sac and scrape it out thoroughly. Correct any error of refraction. Entropion. I . Eyelid is inverted and the lashes rub against the ocular conjunctiva, or cornea, causing great irritation. Treatment. Operation. Ectropion. 1. Eyelid is everted and the patient may be unable to close the lids. The cornea becomes dry, and ulcerative keratitis follows, 2. Not infrequently the punctum is drawn away from the eyeball and the tears are discharged over the edge of the lid and run down on the cheek {epiphora). Treatment. Operation. DISEASES OF THE LIDS (Continued). 77 Paralysis of Orbicularis Muscle (Lagophthalmus) . I. Due to lesion of the seventh nerve. Lids cannot be closed. Con- junctivitis and keratitis follow. Epiphora almost constant. Treatment, Directed to nerve lesion and protec- tion of the cornea. Spasmodic Contractions of Orbi- cularis Muscle (Nictitation), (Nervous Wink). I. Frequent winking of the eyelids without apparent cause. Treatment. Directed to nervous condition. Correct errors of refraction. Ptosis. I. Inability to raise the upper eyelid, either on account of paralysis or mechanical difficulties. May be congenital. Treatment, If paralytic, hg. bi-chl. If mechanical, operation. Xanthelasma. I. Yellow patches of connective tissue, pigment, and fat, in the integu- ment of the lids. Patches usually slightly elevated. Treatment, Operation to remove each patch. Ankyloblepharon . I. Adhesion of free edges of upper and lower lids. Treatment, Operation to free the edges. Symblepharon. I. An adhesion between the palpebral and ocular conjunctiva. Treatment, Operation to separate or break up the adhesion. 78 DISEASES OF THE LACHRYMAL APPARATUS. Inflammation of Lachrymal Gland (Dacryo-adenitis). I . Symptoms are those of inflammation or abscess of the orbit, according to its severity, and can only be diagnosed by the location or point of greatest intensity. Treatment, Poultices, and if pus forms, sub-con- junctival incision. Abscess of Orbit. I. Similar to abscess of other parts. Treat on general surgical principles. Lach. Stricture and Watery Eye or Inflammation of Lach. Sac (Mucocele), (Dacryo-cystitis). I. Epiphora, or, muco-purulent secre- tion between the lids ; pressure over the sac causes the accumu- lated secretion to well up through the punctum. If punctum or stric- ture of canaliculus should close the exit upward, pus may accumu- late in the sac (abscess of the lack, sac), and it may rupture through the integument covering the sac, and leave a fistula (lack, fistula). 2* A probe passed into canaliculus meets obstruction before enter- ing sac, and usually one at the junction of sac and duct. Treatment, Pass probe through sac into duct. Astringent coUyria. Abscess over Lach. Sac I. Similar to abscess of other parts. 2. A probe will pass into the lachry- mal sac without meeting ob- struction. Treatment, Poultice. Incision. ERRORS OF REFRACTION (Ametropia). 79 Hypermetropia of 3. D or less (far sighted). 1. Vision good for distance. 2. Vision good for close work, until eyes tire. 3. Close work causes eye strain, blurred vision, etc. (asthenopia). 4. Distant vision does not cause asthe- nopia. 5. Vision at 20 feet as good, or better with convex glasses (manifest hypermetropia). 6. Vision may be as good with weak concave glasses. Not infre- quently young subjects contract their ciliary muscle (spasm of accommodation) ^ and accept no convex glass (latent hypermet- ropia), and may see better with a concave glass (apparent my- opia). 7. Fine type can be read at 20 inches. 8. With the ophthalmoscope, the ob- server with a perfect eye (etn- metropia), who does not use his accommodation, should see the granular appearance at the ma- cula (of the healthy retina), with the convex glass, which corrects the total hypermetropia. If patient will not accept this glass, it shows latent hypermetropia. Myopia of 3. D or less (near sighted). 1. Vision poor for distance. 2. Vision good for close work for al- most any length of time. 3. Close work does not cause eye strain or headache. 4. Distant vision does not cause eye strain. 5. Vision at 20 feet not as good with convex glasses. 6. Vision improved with weak concave glasses. If ciliary muscle is not relaxed a stronger glass will be required to see distinctly. Anisometropia is not infrequent. 7. Fine tjrpe cannot be read at 20 inches. 8. With the ophthalmoscope the weak- est concave glass with which the granular appearance of the retina can be seen corrects the myopia. 8o ERRORS OF REFRACTION (Continued). Hypermetropia of more than 3. D. 1 . Vision not usually good for distance. 2. Close work causes asthenopia. 3. Vision improved with convex glass. 4. Vision impaired with concave glass. 5. In high degrees of hypermetropia, fine type maybe read at ten (10) inches and cannot be read at 20 inches. Ophthalmoscopic appearances : 6. The disc appears unusually small, often oval, and of a dark pink color, while the retina shows the granular appearance very dis- tinctly. This condition of the disc is spe- cially well marked in the high degree of hypermetropia follow- ing cataract extraction (aphakial eye). It is not infrequent to find the vision of one eye very defective with- out apparent cause (monocular amblyopia). Treatment, Order the strongest convex glass patient can see with distinctly at 20 feet. Myopia of more than 3. D. 1. Vision never good for distance. 2. Close work does not cause asthen- opia. 3. Vision impaired with convex glass. 4. Vision improved with concave glass. 5. In high degrees of myopia fine type cannot be read at ten (10) or more inches. Ophthalmoscopic appearances : 6. The disc appears unusually large ; frequently a staphyloma is seen on the temporal side (see pages 69 and 72). The retinal pigment (post, layer of retina) and choroid may be more or less atrophied, showing the choroidal vessels with the dark irregular interspaces. (The choroidal arteries and veins can- not be distinguished.) They are of a dark orange color and anastamose freely, giving the peculiar appearance known as the ^^ tiger skin fundus. ^^ If the atrophy has progressed fur- ther, black patches of choroidal pigment, and white patches showing choroidal atrophy, will be seen. Treatment. Order the weakest concave glass patient can see with distinctly at 20 feet. Avoid all eye strain. ' ERRORS OF REFRACTION (CONrmuED). 8l 1 Hyperopic Astigmatism. Mjopic Astigmatism. I. Javal-SchoU; Ophlhalmomeler I. Javal - Schollz Ophthalmometer gives the amount and axis of gives the amount and axis of tbe corneal a;li|;matL^m. the corneal astigmalism. 2. A proper convex cyl. glass placed 2. A proper concave cyl. glass placed before the eye, and in the proper before the eye. and in proper aiis, should give normal vision axis, should give normal vision at 20 feet distance (f^.). at 20 feet distance (fg). 3. Vision may bk as good or even 3. A CONCAVE SF. CLASS ADDED TO BETTEE BV ADDING CONVEX SP. THE CONCAVE CVL. MAV BE GLASSES (compound kypermel- NECESSAEV TO SECURE PERFECT ropic astigmatism). VISION (campeund myopic astig- malism). 4. In a (ew rare cases the asligmatism 4. A few cases get the best vision by is irregular, and no cyl. glass adding a convex cyl. glass; axis corrects it ; these subjects occa- at tight angles to the concave sionally complain of monocular cyl. (mir/d astigmatism j. diplopia (polyopia). Ophthalmoscopic appearances : Ophthalmoscopic appearances ; 5. Disc appears oval. 5. Disc appears oval. 6. If the accommodation of the ob- server is fully relaxed, the whole 6. If the accommodation of the ob- server is fully relaxed, the \vhole fundus cannot be seen distinctly fundus cannot be seen distinctly with any one glass. with any one glass. 7. Retinoscopy reveals the fact that 7. Retinoscopyshows only one merid- only one meridian is corrected ian corrected by a sp. glass. by a sp. glass. Shadows reverse (See page 82.) in one meridian iirst. (See page 32.) Treatment. Trtalmint. Order full correction for the astig- Order full correction for the astig- matism, and the weakest concave sp. matism and manifest hypennetropia. patient can see with distinctly at 20 feel. For milted astigmatism order the strongest convex and weakest concave cyl. glass that will give good vision al 20 feel. 82 ERRORS OF JIEFRACTION (Continued). Retinoscopy or shadow test, with concaTe mirror. I. Seated in front of the hjrperopic subject (48 inches), get the red reflex and rotate the mirror FROM RIGHT TO LEFT. A » "shadow" appears on the left side of the red reflex, AND moves across IT TO THE RIGHT ^' moves against^ ), 2. Over-correction with convex glasses causes a reversal of the shadows. 1. Seated in front of the myopic sub- ject (48 inches), get the red reflex and rotate the mirror from RIGHT to left. A SHADOW appears on the right SIDE OF THE REFLEX AND MOVES ACROSS IT TO THE LEFT (^* moves with" J, If myopia is less than .75 D, the shadow *' moves against." 2. Over-correction with concave glasses causes a reversal of the shadows. PRESBYOPIA (Old Sight). Presbyopia and Emmetropia or Hypermetropia. I. Age over 38 or 40. Treatment, If hypermetropia is considerable, it is necessary to correct the error of re- fraction, as well as the failure of the ciliary muscle to affect the convexity of the hardened lens. Add convex glasses until patient is ABLE TO READ fine print at 9 or 10 inches. Presbyopia and Myopia. I. Age over 40 or 42. Treatment, If myopia is considerable, a weaker concave glass is required for close work than for distance. If myopia is slight, vision may be better without any glass, or possibly with a weak convex glass. Anisometropia. I. When there is a difference in the refraction of the two eyes amounting to i D or more, it is termed anisometropia. Antimetropia. I. When one eye is hypermetropic and the other myopic, it is termed antimetropia (Noyes). MUSCLES. 83 Adduction. To determine the adduction, place the apex of the prism over one internal rectus muscle (base out). The strongest prism which does not produce two images (diplopia) measures the adduction. Abduction. To determine the abduction, place the apex of the prism over one external rectus muscle (base in). The strongest prism which does not produce two images measures the abduction. Sursumduction. A prism with apex over sup. rectus (base down) measures the sursum- duction of that side. Deorsumduction. A prism with apex over the inf. rectus (base up) measures the deorsumduction of that side. DIPLOPIA. Crossed Diplopia. Eyes turn out, and the visual lines separate. If the left eye fixes an object the retinal image of the right eye is teceived on the temporal side of the macula, and is projected on the left side of the image seen by the left eye. Homonomus Diplopia. Eyes turn in, and the visual lines cross. If the left eye fixes an object the retinal image of the right eye is received on the nasal side of the macula, and is pro- jected on the right side of the image seen by the left eye. NYSTAGMUS. Involuntary oscillating of the eyes. Usually horizontal, may be rotary. Always the result of defective vision. Treatment. If possible improve vision by aid of glasses. 84 CONCOMITANT SQUINT (Strabismus). Convergent Squint. 1. Only one eye fixes; the visual line or axis is directed to the object, while the other eye turns toward the nose. 2. The visual lines cross. If the squint is recent, and not ex- cessive, each eye may see the object, apparently in two places or positions (diplopia). The right eye projects the object on the right side, and the left eye on the left side (homonymous diplopia). (See page 83.) Frequently the vision of one eye is poor, without apparent change in the retina (amblyopia ex an- opsia), and does not see or ig- nores the image. At times one eye may **tum," and the re- mainder of the time the other (alternating squint), or, a por- tion of the time one eye ' * turns, " and in the intervals both eyes are straight (periodic squint). Treatment, Order full correction glasses. Tenotomy of internal rectus, or advancement of external rectus, or Divergent Squint. 1. Only one eye fixes ; the other eye turns out and away from the nose. 2. The visual lines separate. "When there is diplopia, the right eye projects the object on the left side and the left eye pro- jects the object on the right side (crossed diplopia), (See page 83.) Treatment, Order proper glasses, usually myopic. Tenotomy of external rectus, or ad- vancement of internal rectus or both. both. Vertical Squint. (Strabismus Sursum Vergens) (upward squint), or (Strabismus Deorsum Vergens) (downward squint). The superior or inferior recti muscles are at fault (weak). Treatment. Advancement of the weak, or tenotomy of the strong muscle. INSUFFICIENCY OF OCULAR MUSCLES CDym InanfGciency of the Interni. To delermine i nsii flidency of Ihe before the righl eye with the apex up. Ask the subject 10 lonk at a light twenty feet distant ; tiio lights will be seen. The upper light will be projected on the left of a perpendicular line (crossed dipt^ia). A second prism over Ihe left eye, apex out, which will bring the lights in a vertical line, me^ures the insufHciency, or Insufficiency of the Right laC. Rectus, or Left Sup. Rectus (Right Hyperphoria). To delermine insufficiency of the right inf. or left sup. rectus, a prism of sufficient strength to cause marked diplopia is placed, base in, before the right eye. The light on the patient's right will be projected tielow the hori- zontal line. A second prism over the left eye, apex down, which will bring the lights on the same horizontal plane, measures the right hyperphoria. HypErexophoria, Right and Left, As