Purulent Ophthalmia (ophthalmia of the newly born) is caused by contact of pus from a gonorrheal or leucorrheal discharge or from another eye similarly affected. It is one of the forms of Egyptian ophthalmia. In children both eyes are generally affected; in adults usually one. The symptoms begin, from one to three days after infection, with a watery discharge, which increases rapidly in amount, and becomes yellow and purulent. The conjunctiva becomes greatly congested and swollen, bleeding readily. The lids are so stiffened with infiltration that they can hardly be separated. When they are slightly opened quantities of pus escape. There is great pain in the eye, fever, and sleeplessness. The cornea is much endangered; it may be perforated, may slough wholly or in part, and the eyeball may be destroyed. If one eye only is affected the other must be protected. Locally the greatest cleanliness is necessary, and the discharge must be constantly removed. Once daily the conjunctiva should be touched with a strong solution of nitrate of silver, and in the interval frequently bathed with astringent solutions. Recently, powdered iodoform has been much recommended as a local application. In adults leeching the temple and the continuous application of ice to the eye may be needed. The attendants must be warned of the danger of conveying infection to their own eyes.

Diphtheritic Conjunctivitis is characterized by the formation of a yellowish false membrane on the conjunctiva, which becomes thickened and almost solid from infiltration, and by great liability to sloughing of the cornea. It occurs most frequently in North Germany, attacking weakly children during epidemics of ordinary diphtheria, and, like it, often proves fatal by exhaustion. It should be treated by the internal administration of tonics and stimulants, and by the local use of ice, antiseptic lotions, and the strictest attention to cleanliness.

Chronic Granular Conjunctivitis is a contagious disease arising from prolonged overcrowding under bad sanitary conditions. It is thus specially common among the Jewish and Irish poor, and among workhouse children. The mucous membrane of the lids becomes reddened, thickened, and studded over with small firm “granulations,” like boiled sago grains. The friction of these bodies produces a vascular opacity of the cornea (pannus), at first limited to the upper half of the cornea, but in bad cases involving its whole surface. There is considerable pain and discharge, and the eyelids are kept half-shut. There is a peculiar liability to acute exacerbations. The conjunctiva finally shrinks to a dense white scar, which curves the tarsal cartilage inwards, and brings the edge of the lids and the eyelashes to rub on the cornea, and increase its opacity.

It must be persistently treated by strong astringent or caustic applications to the conjunctiva. The pannus, as a rule, disappears with the granulations that caused it. If not, a zone of conjunctiva round the cornea may be divided; or, as a last resort, the eye may be inoculated with pus from a purulent case. All acute exacerbations must be treated by soothing applications. Incurving of the tarsal cartilage and displacement of the lashes need special surgical operations, which are more or less successful.

If a case occurs in a school or in barracks it must be at once isolated.

Pterygium is a triangular thickening of the exposed part of the conjunctiva, which may or may not be vascular. Its apex is towards the cornea, over which it tends to grow, and thus to interfere with vision; otherwise it causes no irritation. Pterygium is a disease of middle life and of warm climates. If it cause no deformity or interference with sight it should be left alone. If large it may be dissected up from the apex and cut off, or transplanted into another part of the conjunctiva, where it will shrivel up.

The diseases of the cornea are of extreme importance, from their great frequency and from the fact that a small lesion may seriously affect the perfect transparency and regularity of curvature so necessary for clear vision.

Chronic Interstitial Keratitis attacks young persons, nearly all of whom, as was first pointed out by Hutchinson, can be shown to be the subjects of hereditary syphilis, and who present some or all of the following physiognomical characters :—a depressed bridge of the nose, scars at the angle of the mouth, and notched and pegshaped central upper incisor teeth. The disease affects both eyes, ope generally some time before the other. It begins by the appearance of cloudy spots in the cornea, which spread until the whole cornea has a ground-glass appearance, not uniform throughout but with denser opacities here and there. The corneal surface is “steamy.” The ciliary zone of vessels, immediately round the cornea, is congested, and iritis is a frequent complication. As a rule pain and photophobia are not great. The cornea seldom clears in less than a year, and even then only imperfectly. Internally, minute doses of mercurials, or where there is decided struma the syrup of the iodide of iron should be given. Locally, atropine should be used to prevent iritis. As the cornea clears, some stimulant, as the dusting of fine calomel powder, may hasten the absorption of the exudation.

Phlyctenular Ophthalmia occurs in strumous or weakly children, especially after hooping-cough or measles. There is great intolerance of light, the slightest attempt to separate the lids causing a gush of tears. The patient is generally kept in bed in a dark room and buries his head in the pillow to exclude the light. The conjunctiva is reddened generally, but spots of localized congestion are seen near little greyish or yellowish elevations on the conjunctiva, or on the cornea near its margin. These papules or pustules may succeed each other in crops for a long time. On the cornea they give rise to vascular ulcers, which may be single or so numerous as to constitute a condition of pannus. As they heal the vessels shrink, and a small white speck is left to mark the seat of the ulcer. As regards treatment, the patient must have a shade or dark glasses, and be sent out of doors daily when the weather permits. Tonics and nourishing food are required. Locally, so long as the secretion is watery atropine must be used; later, mild astringent lotions; and finally, to aid the healing of the ulcer and clearing of the residual opacities, some mercurial ointment or calomel powder should be applied.

Ulcers of the Cornea.— Ulcers occur under many forms, to which very various names have been given. All the forms have certain symptoms in common with each other and with the above diseases. There is great pain in and about the eye, great intolerance of light (especially in superficial ulcers), and congestion of the ciliary zone. They generally leave an opacity, which greatly interferes with sight if in the centre of the pupil. In severe inflammatory or suppurative ulceration the above symptoms are well marked; the base of the ulcer is greyish in colour, its edges irregular, and the surrounding cornea infiltrated. It extends superficially and deeply, and may cause hypopyon (pus in the base of the anterior chamber), and even perforation of the cornea, or iritis. The weak ulcer has little pain or congestion, and seems simply a loss of substance at one part of the cornea. It causes distorted or multiple images. Its existence is a sign of lowered health, and calls for local stimulation and tonic treatment. The small central ulcer of children is a small greyish funnel-shaped spot in the centre of the pupil, with little pain or congestion. It sometimes goes on to abscess, but usually heals quickly. The senile or serpiginous ulcer is a very serious form. There is great pain and photophobia, and unless treated the ulcer gradually eats its way across the cornea, or extends at its margins so as to isolate the central part of the cornea.

The treatment of corneal ulcers varies very much with the type of disease and with its several stages. In the acute cases the eyes should be shaded, sometimes bandaged; atropine applied locally allays pain; eserine is said to act similarly by reducing tension, and is preferable where conjunctival discharge is aggravated by atropine. The weak ulcer should be touched with a nitrate of silver solution, the senile bathed with a quinine lotion. If the inflammatory ulcer be not checked by atropine, and if hypopyon increase, tension may be diminished by incising the cornea at its margin, or through the base of the ulcer (Saemisch), or by performing iridectomy.

Abscess of Cornea may result from injury or ill-health.

It begins as a yellow spot in the substance of the cornea, with some surrounding haze. It may become absorbed, or burst forwards and be converted into an inflammatory ulcer, or backwards, giving rise to hypopyon. If hot fomentations and atropine do not check it, it must be treated surgically like the inflammatory ulcer.

Staphyloma of the Cornea is a bulging forward in whole or in part of the new tissue which replaces the cornea after ulceration or sloughing. It has a bluish or greyish colour, and may be slight in amount, or so great as to keep the eyelids widely separated and cause great irritation. When there is no irritation it may be left alone; when it is increasing an iridectomy may check its progress. When it is large and causes irritation the eye may be removed entirely, or in part so as to leave a stump on which to fit an artificial eye.

Conical Cornea occurs principally in young women whose health has been much reduced from some chronic cause. The cornea becomes thinned in the centre, and is slowly bulged forward. The condition, which is easily recognized from the glistening appearance and the conical form of the cornea, causes great myopia, which can be only imperfectly remedied by biconcave lenses obscured except at a small central aperture or slit. In severe cases operation may be of some service.

Keratitis Punctata is usually secondary to some deeper-seated disease, e.g., iritis, choroiditis, or sympathetic ophthalmitis. Minute greasy-looking dots are deposited at the back of the lower part of the cornea, generally arranged as a triangle with its apex upwards. The ocular tension and amount of aqueous humour increase. The treatment is that of the causal disease, usually iodide of potassium or a mercurial, with atropine locally.

Arcus Senilis is a whitish crescent or ring just inside the corneal margin. It is a senile change, a fatty degeneration of the corneal tissue, not necessarily accompanied by fatty degeneration elsewhere. It does not influence the healing of corneal wounds in any way.

In Acute Iritis the iris changes in colour and its fibres lose their definition and look muddy. The pupil becomes small, irregular in outline, and sluggish or immobile when stimulated by light. There is a pink zone of congestion round the cornea (the ciliary zone). The aqueous humour is turbid; it may contain blood, and even pus. There is more or less pain in the eye and temple, which is usually worst at night; there is intolerance of light, great increase in the secretion of tears, and impairment of sight. In most cases lymph escapes from the posterior surface of the iris and fixes its margin to the lens at one or more points, or all round, and may even occlude the pupil. In some cases the exudation is entirely serous and no adhesions are formed (serous iritis). Iritis is one of the symptoms of secondary syphilis; it is caused by rheumatism, by ulcers and diffuse inflammations of cornea, by injuries to the cornea, iris, and lens, and forms part of nearly all cases of sympathetic ophthalmitis. The syphilitic form usually involves both eyes; it produces much exudation and often little yellow nodules, and rarely relapses. Rheumatic iritis is generally serous, unilateral, and recurs frequently. Atropine must be freely applied locally to prevent the formation of adhesions, or to break down such as may have already formed. The temple may be leeched, and opiates given if pain is severe. In the syphilitic forms calomel must be given; in the rheumatic alkalis and colchicum. The eyes must be protected by a shade. Traumatic iritis should be treated by continuous cold and leeching. If it is due to a swollen lens, the latter must be removed. After the disease is past the pupil is frequently irregular from adhesions (synechiae) of the iris to the lens-capsule. If adhesions have been broken down small brown specks will be seen in the pupil. The whole free edge (exclusion), or the whole posterior surface (total posterior synechiae), may adhere to the lens-capsule, and the pupil may be completely covered with a film of lymph (occlusion). These three last conditions are apt to cause secondary glaucoma.

Coloboma of the Iris is a congenital defect in the iris. The defect is always in the lower part, and gives the pupil a balloon shape. It may or may not be accompanied by a similar defect in the choroid and retina.

From the intimate association of their vascular supply, the ciliary body, iris, cornea, sclerotic, and choroid are frequently affected together. Diseases in this region all agree in their tendency to relapse frequently during a very chronic course, and to involve separate patches.

Sclerotitis (episcleritis) forms a low painful swelling, of a peculiar rusty colour, under the conjunctiva in the ciliary region. It lasts for months, with frequent relapses. The subjects of this disease are mostly rheumatic or anaemic women. Internally, iodide of potassium is sometimes useful. If that fail small doses of mercury should be given. Locally, atropine, blistering the temple, or massage of the swelling through the upper lid may be tried.

Irido-cyclitis, inflammation of the iris and ciliary body, is characterized by congested patches of a violet colour in the ciliary region, cloudy areas in the cornea, and attacks of iritis with much plastic exudation. There is great pain and intolerance of light. It relapses frequently, each attack leaving more cloudiness of cornea and more iritic adhesions, till ultimately the sclerotic presents a bluish bulging in the ciliary region (ciliary staphyloma), the cornea is opaque, its curvature irregular, and the sight gone.

Irido-choroiditis resembles a mild attack of iritis; there is little pain or photophobia. Small deposits form on the back of the cornea (keratitis punctata). Recent choroiditis and sometimes opacities in the vitreous may be seen with the ophthalmoscope if the pupil be clear. This also relapses frequently, with the formation of much iritic adhesion, and sometimes of secondary glaucoma. This occurs mostly in delicate young persons, and generally involves both eyes. The treatment consists of atropine locally, disuse of the eyes, and tonics with iodide of potassium internally; only in mild cases is a good result obtained. The iritic exudation is generally too plastic to be absorbed.

Wounds or Diseases in the Ciliary Region are extremely liable to involve the other eye sympathetically. There are two affections of very different moment. In sympathetic irritation the eye is tender and irritable, cannot bear a bright light, and is easily fatigued by continued strain of the accommodation, as in reading or other close work. This condition usually yields speedily when the other eye is removed, which should be advised without hesitation. Sympathetic inflammation is of much more serious moment. It may begin quite insidiously, or with acute pain and intolerance of light. Once begun, it becomes an independent disease, little influenced by treatment directed to the exciting eye, and usually ending at last in irreparable blindness. The symptoms are deposits on the back of the cornea (keratitis punctata), violet-coloured ciliary congestion, often great tenderness of the ciliary region, the iris muddy and in severe cases buff-coloured, and with many large blood-vessels on its surface. Extensive iritic adhesions form which cannot be absorbed. The process is an irido-cyclitis or irido-choroiditis. It may be set up two months or many years after the injury; the eye is never safe. Treatment must evidently be mainly preventive. All blind eyes liable to cause sympathetic inflammation should be at once removed. If some vision be left in the wounded eye, and the patient can be kept under observation, it may be left,—the patient being warned of the danger to the other eye. The inflammation once arisen, the exciting eye, if blind, must be removed; but not if there be any sight in it, as it may be eventually the better eye of the two. The patient must be kept in a dark room and not allowed to use his eyes. Atropine solution must be applied locally. After the inflammation is quite quiescent removal of the lens with a portion of the iris may be of use in giving an artificial pupil.

Cataract.— Cataract is an opacity of the crystalline lens. It is due to some alteration in the structure and relationship of its fibres, as the result either of some senile change or defect of development, of local interference with its nutrition (as in glaucoma), of some general diseases such as diabetes, or of local injury to the lens or its capsule. For practical purposes all cataracts are classified under three categories. (A) They may be hard or soft; below the age of thirty-five, and in diabetes of any age, cataracts are soft. (B) They may be general or partial, according to the amount of lens involved in the opacity. General cataract may be nuclear (beginning from the centre) or cortical (spreading inward from the periphery); or both conditions may coexist. Partial cataract may be (1) lamellar, where one or several of the concentric layers in an otherwise transparent lens becomes opaque. This form is often congenital. It is said to be frequently caused by infantile convulsions. (2) Pyramidal cataract is a small white spot on the lens-capsule in the centre of the pupil. This is the result of corneal perforation in purulent ophthalmia. The cornea falls against the lens-capsule when the aqueous humour is evacuated, and becomes adherent to it. The aqueous, refilling after the healing of the perforation, tears away the cornea and leaves the spot of lymph on the capsule. (3) In posterior polar cataract the opacity begins at the posterior pole of the lens. It indicates deep-seated disease. (C) Cataract may be primary or secondary, according as it arises in an eye otherwise healthy or depends on some other disease in it. Cataracts arising from injury to the lens are called traumatic. Symptoms and Treatment of Cataract.— Vision becomes gradually impaired. If the cataract be small and central, vision improves in a dull light or when the eyes are shaded. On ophthalmoscopic examination (see below) the opaque parts appear either as dark striae converging towards the centre or as a dark central mass. The fundus, if visible, appears red. An attempt should be made to ascertain if it is healthy. On oblique illumination by a convex lens the opaque parts now appear white and the rest of the pupil black. When the cataract is ripe the pupil is filled by a homogeneous pearly-white or amber-coloured opacity. The rest of the eye is healthy if the pupil reacts to light, and the patient can tell the direction of a candle-flame at four feet distance. As a palliative atropine may be used if it be found to improve vision. To remove the cataract operation is...