years. The subjective symptoms vary in intensity with the
severity of the inflammation. There is always more or less
troublesome “burning” in the eyes with a tired heavy feeling
in the lids. This is aggravated by reading, which is most distressing
in a close or smoky atmosphere and by artificial light.
In acute cases, indeed, reading is altogether impossible. In all
cases of catarrhal conjunctivitis the symptoms are also more
marked if the eyes have been tied up, even though this may
produce a temporary relief.
A curious variety of acute catarrhal conjunctivitis, in which the hyperaemia and lacrymation are the predominant features, is the so-called hay-fever. In this condition the mucous membrane of the nose and throat are similarly affected, and there is at the same time more or less constitutional disturbance. Hay-fever is due to irritation from the pollen of many plants, but principally from that of the different grasses. Some people are so susceptible to it that they invariably suffer every year during the early summer months. Here it is difficult to remove the cause, but many cases can be cured and almost all are alleviated be means of a special antitoxin applied locally.
Other ectogenetic causes of catarrhal conjunctivitis which have been studied are mostly microbic. Of these the most common are the Morax-Axenfeld and the Koch-Weeks conjunctivitis.
The Morax-Axenfeld bacillus sets up a conjunctivitis which affects individuals of all ages and conditions and which is contagious. The inflammation is usually chronic, at most subacute. It is often sufficiently characteristic to be recognized without a microscopical examination of the secretions. In typical cases the lid margin, palpebral conjunctiva, and it may be a patch of ocular conjunctiva at the outer or inner angle are alone hyperaemic: the secretion is not copious and is mostly found as a greyish coagulum lying at the inner lid-margin. The subjective symptoms are usually slight. Complications with other varieties of catarrhal conjunctivitis are not uncommon. This mild form of conjunctivitis generally lasts for many months, subject to more or less complete disappearance followed by recurrences. It can be rapidly cured by the use of an oxide of zinc ointment, which should be continued for some time after the appearances have altogether passed off.
The conjunctivitis caused by the Koch-Weeks microbe is still more common. It is a more acute type, affects mostly children, and is very contagious and often epidemic. Here the hyperaemia involves both the ocular and the palpebral conjunctiva, and usually there is considerable swelling of the lids and a copious secretion. Both eyes are always affected. Occasionally the engorged conjunctival vessels give way, causing numerous small extravasations (ecchymoses). Complications with phlyctenulae (vide infra) are common in children. The acute symptoms last for a week or ten days, after which the course is more chronic. Treatment with nitrate of silver in solution is generally satisfactory. Other less frequent microbic causes of catarrhal conjunctivitis yield to the same treatment.
A form of epidemic muco-purulent conjunctivitis is not uncommon, in which the swelling of the conjunctival folds and lids is much more marked and the secretions copious. It is less amenable to treatment and also apt to be complicated by corneal ulceration. The microbe which gives rise to this condition has not been definitely established. This inflammation is also known as school ophthalmia. This is extremely contagious, so that isolation of cases becomes necessary. The treatment with weak solutions of sub-acetate of lead during the acute stage, provided there be no corneal complication, and subsequently with a weak solution of tannic acid, may be recommended.
Purulent Conjunctivitis.—Some of the severer forms of catarrhal conjunctivitis are accompanied not only by a good deal of swelling of both conjunctiva and lids but also by a decidedly muco-purulent secretion. Nevertheless there is a sufficiently sharply-defined clinical difference between the catarrhal and purulent types of inflammation. In purulent conjunctivitis the oedema of the lids is always marked, often excessive, the hyperaemia of the whole conjunctiva is intense: the membrane is also infiltrated and swollen (chemosis), the papillae enlarged and the secretion almost wholly purulent. Although this variety of conjunctivitis is principally due to infection by gonococci, other microbes, which more frequently set up a catarrhal type, may lead to the purulent form.
All forms are contagious, and transference of the secretion to other eyes usually sets up the same type of severe inflammation. The way in which infection mostly takes place is by direct transference by means of the hands, towels, &c. , of secretions containing gonococci either from the eye or from some other mucous membrane. The poison may also sometimes be carried by flies. The dried secretion loses its virulence.
In new-born children (ophthalmia neonatorum) infection takes place from the maternal passages during birth. Notwithstanding the great changes which occur during the progress of a purulent conjunctivitis, there is on recovery a complete restitutio ad integrum so far as the conjunctiva is concerned. Owing to the tendency to severe ulceration of the cornea, more or less serious destructions of that membrane, and consequently more or less interference with sight, may result before the inflammation has passed off. This is a special danger in the case of adults. For this reason when only one eye is affected the first point to be attended to in the treatment is to secure the second eye from contagion by efficient occlusion. The appliance known as Buller’s shield, a watch-glass strapped down by plaster, is the best for this purpose. It not only admits of the patient seeing with the sound eye, but allows the other to remain under direct observation. The treatment otherwise consists in frequent removal of the secretions from the affected eye, and the use of nitrate of silver solution as a bactericide applied directly to the conjunctival surface; sometimes it is necessary to cut away the chemotic conjunctiva immediately surrounding the cornea. When the cornea has become affected efforts may be made with the thermo-cautery or otherwise to limit the area of destruction and thus admit of something being done to improve the vision after all inflammation has subsided. The greatest cleanliness as well as proper antiseptic precautions should of course be observed by every one in any way connected with the treatment of such cases.
Phlyctenular conjunctivitis is an acute inflammation of the ocular conjunctiva, in which little blebs or phlyctenules form, more particularly in the vicinity of the corneal margin, as well as on the epithelial continuation of the conjunctiva which covers the cornea. The inflammation is characterized by being distributed in little circumscribed foci and not diffused as in all other forms of conjunctivitis. In it the conjunctival secretion is not altered, unless there should exist at the same time a complication with some other form of conjunctivitis. This condition is most frequent in children, particularly such as are ill-nourished or are recovering from some illness, e.g. measles. The susceptibility occurs in fact mainly where there exists what used to be called a “strumous” diathesis. In many cases, therefore, there is some kind of tubercular basis for the manifestations. This basis has to do with the susceptibility only, at all events to begin with. The local changes are not tuberculous; their exact origin has not been clearly established. They are in all probability produced by staphylococci.
Many children suffering from phlyctenular conjunctivitis get after a short time an eczematous excoriation of the skin of the nostrils. This excoriated, scabby area contains crowds of staphylococci which find a nidus here, where the copious tear-flow down the nostrils has excoriated and irritated the skin. Lacrymation is indeed a very common concomitant of phlyctenular conjunctivitis. Another frequently distressing symptom is a pronounced dread of light (photophobia), which often leads to convulsive and very persistent closing of the lids (blepharospasm). Indeed the relief of the photophobia is often the most important point to be considered in the treatment of phlyctenular conjunctivitis. The photophobia may be very severe when the local changes are slight. The eyes should be shaded but not bandaged. Cocain may be freely used. The best
