Diseases of the Eyelids:
-E.B.Norton
Anatomy.- The eyelids form the external covering of the eyeballs and serve to protect the eye from injury both from excessive light and foreign substances; they also serve at the same time to distribute to the eyes the moisture secreted by the various glands.
The eyelids or palpebrae, are two thin movable folds, the upper being the larger and more movable of the two; their movement is both voluntary and involuntary, the latter action being due to the orbicularis muscle. The opening of the lids is chiefly by the action of the levator palpebrae superiors lifting the upper lid; when opened an elliptical space is left between the margins of the lids; this opening varies greatly, being larger in prominent eyes than in sunken ones and greater when looking upward. The angles of junction of the upper and lower lids are called canthi the outer canthus is more acute than the inner; near the extremity of the inner canthus is found on both the upper and lower lids a slight elevation, the apex of which is pierced by a small orifice, the punctum lachrymale, the commencement of the small channel or canaliculus leading to the tear sac.
The eyelids are composed of four layers, arranged from without inward in the following order, the integument, a layer of muscular fibres, the tarsus or as often erroneously called the tarsal cartilage, and the conjunctiva. The integument, which is extremely thin but similar in every other respect to the integument elsewhere, becomes at the margin of the lids, conjunctiva. The integument which is extremely thin but similar in every other respect to the integument elsewhere becomes, at the margin of the lids, continuous with the conjunctiva. Beneath the skin the connective tissue is loose and contains no fat.
The muscular fibres consist of the orbicularis palpebrarum a large flat, voluntary muscle extending over the orbital margins above and below and terminating by tendinous attachments at the angles of the lids, the tendons, together with some fibres of the muscle, being inserted in the adjacent bony wall. The fibres of the orbicularis which lie upon the tarsi are paler than the others, and certain bundles of these give to the lid its involuntary action are known as the ciliary muscles of Riolani. The orbicularis is somewhat adherent to the skin, but glides loosely over the tarsus. It receives its nerve supply from the facial. Its fibres being more or less circular in arrangement, and acting as a sphincter serve to close the eyes.
The levator palpebrae superioris arises at the apex of the orbit, and passing along its upper wall becomes intermingled in front of the tarsus with the orbicularis; other fibres become attached to the upper edge of the tarsus,and still others go to the conjunctiva. This muscle is supplied by a branch from the third nerve and its action, is as its name implies, to raise the upper lid. The lower lid is supplied with a prolongation from the inferior rectus, whose insertion and action is analogous to that of the levator palpebrae.
The tarsi are two thin, elongated plates composed of condensed fibrous tissue, and serve to form the framework of the lids; they are united to each other and to the adjacent bone through the medium of the internal and external lateral ligaments.
The conjunctiva is a delicate mucous membrane which commences at the free border of the lid where it is continuous with the skin; it lines the inner surface of the lids and is then reflected upon the globe, over which it passes and becomes continuous with the cornea. The palpebral portion is thicker and more vascular than that covering the globe and is firmly attached to the tarsus. Where it passes from the lids to the globe it is thin and loose, and forms what are called the fornix conjunctiva. The plica semilunaris is a vertical fold of conjunctiva at the inner canthus, and the reddish elevation at the inner angles is called the caruncula lachrymalis.
The cilia are short, thick, curved hairs, arranged in double or triple rows at the margins of the lids; their follicles are surrounded by sebaceous glands and the glands of Moll. Within the tarsus are embedded the Meibomian glands, which in structure resemble the sebaceous glands. These various glands by their secretions serve to lubricate the eye, and discharge their secretion through excretory ducts opening by minute orifices upon the free border of the lids between the rows of cilia.
Blepharitis._ (Blepharitis Simplex, Blepharo-Adenitis, Blepharitis Ciliaris, Blepharitis Marginalis, Seborrhoea; Blepharitis Ulcerosa, Blepharitis Hypertrophica or Squamosa) Under this general heading inflammation of the lids, we shall group the various clinical sub-divisions. The numerous names (of which the above are but few) that have been given to an inflammation involving the border of the eyelids may be all grouped under two headings-non-ulcerative and ulcerative blepharitis.
SYMPTOMS.- The non-ulcerative form commences as a simple hyperaemia of the lid-border, which gives to the lids a red, swollen appearance. This is accompanied by a slight burning and smarting in the eyelids which is aggravated by cold winds, smoke, dust, exposure to bright light or use of the eyes at close work. There is agglutination of the eyelids in the morning, with dry scales or scabs adhering to the margins of the lids and more or less photophobia and lachrymation are present. This variety depends upon an abnormal secretion of the sebaceous glands.
The ulcerative variety may be considered as an extension of the preceding form. If we remove with the forceps the yellow crusts surrounding and embedding the cilia which have formed through neglect in the previous stage we find a red, bleeding ulcerative surface. This surface to secrete pus that forms other crusts, and by extension of the ulceration the entire edge of the lid may become involved. At this stage the disease is know as blepharitis ulcerosa, and as it advances the edge of the lid not only becomes red and covered with scales, but considerably thickened, and it is then termed blepharitis hypertrophica. It the disease still continues unchecked it involves the hair follicles and causes the lashes to become stunted and misplaced (trichiasis), or to fall out, and when entirely wanting we have the condition known as (medarosis). The final stage of the disease is when the lid itself becomes rounded, red, thickened, everted and deprived of lashes (lippitudo).
COURSE.- The course of the disease is usually very chronic and yet should be cured by thorough and prolonged treatment.
CAUSES: The disease is especially the result of refractive errors in young, delicate persons of a strumous diathesis. As the causes are so closely associated with the treatment, they will be considered further under that heading.
TREATMENT.- First, we should examine the refraction and if any error is found, correct the same with the proper glass as in many cases this alone will cure the entire trouble.
In rare cases the presence of lice on the eyelashes may be the exciting cause (phthiriasis ciliarum), when we should be careful to remove them and apply either cosmoline or some mercurial ointment, which will destroy them and prevent their recurrence.
Fungous growths in the hair follicles are also said to cause this disease, in which case the hairs should be extirpated, and either external or internal medication employed.
Another cause is frequently found in affections of the lachrymal canal, particularly catarrh of the lachrymal sac and stricture of the duct; in these cases the tears, being hindered from flowing through their natural passage into the nose collect in the eye, flow over the lids and down the cheek; thus the retention of the tears will cause an inflammation of the margins and eventually of the whole structure of the lids. Any other affection which will have the same result (flowing of the tears over the lids) will of course, produce the same trouble and this is often found in slight degrees of eversion of the lower lids (ectropium), which displaces the puncta lachrymalis and thus prevents the tears from passing into the sac. In all such cases the first thing to be done is to open the canaliculus into the sac, and, if necessary, the nasal duct into the nose so as to give a free passage for the tears into that organs, after which the treatment is the same as in uncomplicated cases.
But the most common causes of ciliary blepharitis are exposure to wind, dust, smoke etc., especially when complicated with want of cleanliness; it is for this reason we see this trouble so frequently among the poorer classes. As it is upon this point-cleanliness -that the success of our treatment depends to a great extent, we should impress upon the patient is mind the necessity of it in terms as forcible as possible.
They should be directed to remove the scales or crusts from the margins of the lids as soon as formed, not allowing them to remain even a few minutes. This should not be done by rubbing, as the patient is inclined to do on account of the itching sensation, for by so doing excoriations are made, lymph is thrown out and new scabs form, which only aggravate the inflammation. But they should be directed to moisten the crusts in warm water and then carefully remove them with piece of fine linen or by drawing the cilia between the thumb and fingers; at the same time gentle traction may be made on the lashes, so as to remove all that are loose as they act only as foreign bodies. Sometimes the scabs are so thick and firm that moistening in warm water is not sufficient to remove them; in such cases, hot compresses or poultices should be applied for ten or twenty minutes at a time until they can be easily taken away.
In the treatment of chronic inflammation of the margins of the lids, external application are of great value and without their use a cure is often impossible. It is true that a careful attention to cleanliness, together with the internal administration of the indicated remedy, will cure a large proportion of the cases but the duration of treatment will be usually much longer than if we employ local means at the same time we give internal remedies.
Cosmoline or Vaseline.- This unguent has been of great service in the treatment of blepharitis. It may be used alone or to form a base for the administration of other remedies. It prevents the formation of new scales and the agglutination of the lids, besides seeming to exert a beneficial influence over the progress of the disease. This, like all other ointments, should be used once or twice a day, or even oftener if the case is very severe. All scales or crusts should be carefully removed; after which a very little of the ointment may be applied to the edge of the lids with the finger or a camel's hair brush. The smallest amount possible, to oil the ciliary margins of the lids should be applied, as aggravation of the inflammation may result from its too free use.
Mercury.- For years this has been a favorite local application in blepharitis. It seems to be better adapted to the severe forms of inflammation of the lids than Graphites, for there, is more redness, more swelling, more secretion and more tendency toward ulceration. The two following prescriptions have been employed with the most favorable results, especially the yellow oxide:
Rx. Hydrarg oxyd. flav., ..............gr. ij.
Vaseline, ..........................3 ij.
Misce.
Rx. Liq. Hydrarg nitr...................gtt. iij.
Vaseline, ..........................3 ij.
Misce.
In some cases more of the mercury is used, in others less according to the severity of the symptoms.
Grapho-Vaseline- Graphites, as will be seen in the symptomatology, is more commonly indicated in blepharitis than any other one remedy. Many cures have resulted from its internal administration alone, when indicated but more brilliant results may be obtained by employing at the same time locally the following unguentum.
Rx Graphites......................... gr.ij Vaseline, ......................... 3ij
Misce.
Various other ointments and washes have been used with variable success. The use of milk cream, lard and simple cerate, to prevent the lids from sticking together have also been of aid with internal medication.
Graphites.- This in one of the most important remedies we possess for the chronic form of this disease, though it may be indicated in acute attacks, especially if complicated with ulcers or pustules on the cornea. Particularly useful if the inflammation occurs in scrofulous subjects covered with eczematous eruptions, chiefly on the head and behind the ears; which are moist fissured and bleed easily. The edges of the lids are slightly swollen, of a pale red color and covered with dry scales or scurfs or the margins may be ulcerated. The inflammation may be confined to the canthi especially the outer, which have a great tendency to crack and bleed upon any attempt to open the lids. Burning and dryness of the lids are often present, also biting and itching causing a constant desire to rub them. It is important in eczema of the lids if the eruption is moist with tendency to crack while the margins are covered with scales or crusts.
Mercurius sol.- Very favorable results have been gained by this remedy in blepharitis, especially if dependent upon or found in a syphilitic subject or if caused from working over fires or forges. The lids are thick red, swollen and ulcerated (particularly the upper) and sensitive to heat or cold and to touch. Profuse acrid lachrymation is usually present which makes the lids sore, red and painful, especially worse in the open air or by the constant application of cold water. All the symptoms are worse in the evening after going to bed and from warmth in general, also from the glare of a fire or any artificial light. The concomitant symptoms should receive special attention as excoriation of the nose from the acrid coryza, flabby condition of the tongue, nocturnal pains etc.
Hepar Sulph.- The is the remedy most frequently employed in acute phlegmonous inflammation, especially after the first stage has passed and suppuration is about to, or has already taken place. The lids are inflamed, as if erysipelas had invaded them, with throbbing, aching, stinging pains, and very sensitive to touch; the pains are aggravated by cold and from contact, but ameliorated by warmth. It may also be useful in certain forms of blepharitis in which the lids are inflamed sore and corroded, as if eaten out or if small red swellings are found along the margins of the lids, which are painful in the evening and upon touch. There is general amelioration from warmth. Often called for when the Meibomian glands are thick and honeycombed in character on and around the lids, it is very valuable.
Pulsatilla.- Blepharitis, both acute and chronic especially if the glands of the lids are affected (blepharo-adenitis) or when there is a great tendency to the formation of styes or abscesses on the margin of the palpebrae. Blepharitis resulting from high living or fat food and when accompanied by acne of the face; also in cases in which the lachrymal passages are involved. The swelling, redness and discharges vary, though the latter are more often profuse and bland, causing agglutination of the lids in the morning. Itching and burning are the chief sensations experienced. The symptoms are usually aggravated in the evening in a warm room or in a cold draught of air, but ameliorated in the cool open air.
Calcarea carb.- Blepharitis occurring in persons inclined to grow fat, or in unhealthy "pot-bellied" children of a scrofulous diathesis who sweat much about the head. The lids are red, swollen and indurated. Inflammation of the margins of the lids, causing loss of the eyelashes, with thick, purulent excoriating discharge and burning, sticking pains. Great itching and burning of the margins of the lids, particularly at the canthi; throbbing pain in the lids. Most of the eye symptoms are worse in the morning, on moving the eyes and in damp weather. Great reliance should be placed on the general cachexia of the patient.
Calcarea iod.- Seems to act better than the carbonate in blepharitis found in those unhealthy children afflicted with enlargement of the glands and especially of the tonsils.
Rhus tox.- Its chief use is in acute phlegmonous inflammation of the lids and erysipelas; lids oedematously swollen (especially the upper) and accompanied by profuse lachrymation; there may be erysipelatous swelling of the lids, with vesicles on the skin; chemosis is often present. The pains are worse at night, and in cold, damp weather but relieved by warm application. It may be of service in acute aggravations of chronic inflammation from exposure in wet weather or when worse at that time, with much swelling of lids and profuse lachrymation.
Mezereum.- Blepharitis accompanied by tinea capitis; or eczema of the lids and head, characterized by thick hard scabs, from under which pus exudes on pressure.
Antimonium crud.- Obstinate cases in which the lids are red, swollen and moist with pustules on the face. Especially in cross children. Pustules on the ciliary margins.
Arsenicum.- Inflammation of the margins of the lids, which are thick, red and excoriated by the burning, acrid lachrymation. The cheek may also be excoriated. The lids are sometimes oedematously swollen and spasmodically closed, especially when the cornea is at the same time affected. The characteristic burning pains are important and usually present. The general condition of the patient decides us in the selection, as the great prostration, restlessness, aggravation after midnight and thirst are commonly seen in scrofulous children. Often useful in the early stages of abscess of the lids.
Sulphur.- A remedy called for especially in the chronic form of this disease and when found in children of a strumous diathesis who are irritable and cross by day and restless and feverish by night; also for blepharitis appearing after the suppression of an eruption or when the patient is covered with eczema. The lids are red, swollen and agglutinated in the morning or there may be numerous small itching pustules on the margins. The pains are usually of a sticking character though we may have itching, biting, burning and a variety of other sensations in the lids. There is generally great aversion to water so that they cannot bear to have the eyes washed. Eczematous affections of the lids, like eczema in other portions of the body, which indicate Sulphur, are often controlled.
Psorinum.- Old chronic cases of inflammation of the lids especially when subject to occasional exacerbations. It has also been of service in the acute variety when the internal surface of the lids was chiefly affected with considerable photophobia. Particularly indicated in a strumous diathesis with unhealthy, offensive discharges from the eyes.
Aconite.- Chiefly called for in the acute variety of this trouble especially when caused from exposure to cold dry winds and in the very first stage of abscess. The lids-especially the upper - are red and swollen with a tight feeling in them, while great heat, dryness, burning and sensitiveness to air are present; the dry heat is temporarily relieved by cold water. The conjunctiva is usually implicated.
Alumina.- Chronic inflammation of the lids (particularly if complicated with granulations) characterized by burning and dryness of the lids especially in the evenings; itching dryness, and excoriation at the canthi. Absence of lachrymation. There is not usually much destruction of tissue not great thickening of the lids.
Apis mel.- Incipient stage of abscess before the formation of pus, if there is great puffiness of the lids, especially of the upper with stinging pains. Much reddish-blue swelling of the lids; temporary relief from cold water. There is often chemosis and the lachrymation is profuse, hot and burning (Rhus), though not acrid, as under Arsenicum. Drowsiness and absence of thirst are often present.
Argentum nit.- Lids sore, very red and swollen especially when complicated with granular conjunctivitis or some other external trouble. There is usually profuse discharge from the eyes, causing firm agglutination in the morning. The symptoms are often relieved in the cold air, or by cold application and may be associated with headache, pain in the root of nose, etc.
Aurum.- Rarely useful in uncomplicated blepharitis, except when occurring in scrofulous or syphilitic subjects, after the abuse of Mercury. The lids may be red and ulcerated, with stinging, pricking or itching pain in them. Cilia rapidly fall out.
Causticum.- Blepharitis, with warts on the eyebrows and lids. The symptoms are ameliorated in the open air. Feeling of sand in the eye.
Chamomilla.- Of benefit as an intercurrent remedy, even if it does not complete the cure, in cross, peevish children who want to be carried. The local symptoms are not marked,
Cinnabaris.- Ciliary blepharitis, with dull pain over or around the eye. There may be dryness of the eye, or considerable discharge. Croton tig.- When there is complicated with the blepharitis a vesicular eruption on the lids and face.
Euphrasia.- A valuable remedy if the lids are red, swollen and excoriated by the profuse, acrid, muco-purulent discharge, or even if ulcerated. The lachrymation is also profuse, acrid and burning; often accompanied by fluent coryza. The cheek around the eye is usually sore and red from the nature of the discharges.
Mercurius Corr.- This from of Mercury differs very little in its symptomatology from the solubis, and that is chiefly in degree, as the pains are generally more severe and spasmodic in character, lachrymation more profuse and acrid, secretions thinner and more excoriating and inflammatory swelling greater than in any other preparation. It has proved curative in inflammatory swelling of indurated lids; inflammatory swelling of cheeks and parts around the orbits which are covered with small pustules and especially in scrofulous inflammation present.
Natrum mur.- Ciliary blepharitis, particularly if caused by the use of caustics (nitrate of silver). The lids are thick and inflamed, smart and burn, with a feeling of sand in the eye. The lachrymation is acrid, excoriating the lids and cheeks, making them glossy and shining; often accompanied by eczema.
Nux-vom.- Chronic inflammation of the lids,with smarting and dryness, especially worse in the morning. It is particularly indicated in blepharitis dependent upon gastric disturbances.
Petroleum.- Has been of benefit in blepharitis, especially if combined with the use of cosmoline externally. Great reliance should be placed on the occipital headache, rough skin, etc., generally found when this drug is indicated, though it has been used with advantage when no marked symptoms were present.
Sepia.- Chronic inflammation of the edges of the lids with scales on the cilia and small pustules on the lid margins (acne ciliaris). Feeling as if the lids were two heavy or as if they were too tight and did not cover the ball. Worse morning and evening.
Silicea.- Blepharitis from working in a damp place or being in the cold air. (Calc., Rhus.) Indicated in abscesses, after suppuration has commenced. Silicea is more particularly called for in the carbuncular form and especially if the patient is very nervous and the local symptoms are accompanied by sharp pains in the head, relieved by wrapping up warm.
Staphisagria.- Bleeding in which the margins of the lids are dry, with hard nodules on the borders and destruction of the hair follicles. Itching of the lids.
Tellurium.- Eczema of the lids especially if complicated with a moist eruption behind the ears and offensive otorrhoea smelling like fish brine.
In addition to the above, the following remedies have also proved serviceable: Lycop., Merc., nitr., Merc. prot., Sang., Senega. Abscess of the Lid.- (Phlegmon, Furuncle).- Suppuration in the connective tissue of the lid is generally the result of trauma, and is then due to a breaking down of the blood-clot formed at the time of the contusion. It may also follow debilitating diseases, or be associated with adenitis in scrofulous children. There will be great swelling of the lid, with more or less heat, redness and pain. Fluctuation maybe detected early and inflammation of the conjunctiva is apt to be associated with this disease. General inflammation of the lid may sometimes be seen in children without suppuration; while in cachectic subjects we may have a gangrenous condition. Furuncle differs from abscess or phlegmon, in that it is less diffuse, less evidence of fluctuation and more necrosis of tissue.
TREATMENT.- By a careful selection of our remedy in the first stage, we can often cause the inflammation to subside before suppuration has taken place. It is also possible to promote the resolution and discharge of pus already formed. Cold (iced) application are recommended if the disease is seen at the outset; but if we suspect that the formation of pus has commenced,a change to hot applications (poultices) should be made.
As soon as fluctuation can be felt, a free incision into the swelling parallel to the margin of the lids should be made in order to give free vent to the confined pus. After the escape of the pus, warm application of Calendula and water (ten drops to the ounce) are advised. A compress bandage should also be employed if the abscess is extensive, so as to keep the lid in position and the walls of the abscess in contact and thus hasten the union.
If it has already spontaneously opened, the perforation should be enlarged if it be insufficient and unfavorably situated; also if there be several apertures, they should be united by an incision, in order to leave as small a cicatrix as possible. A generous diet should be prescribed. For remedies, see blepharitis page 107.
Hordeolum (Stye, Acne). Is an acute inflammation of the cellular tissue of the lid leading to suppuration and pointing at the edge of the lid. The location of the inflammation is usually in the tissue surrounding a hair follicle.
SYMPTOMS.- At first it appears as a hard circumscribed redness and swelling which frequently extends so that the whole lid will become oedematously swollen. There is at first much severe throbbing pain. Occasionally there are two or more at the same time, and they often occur in successive crops.
COURSE.- They usually point and break in three or four days, though they may undergo absorption without breaking.
CAUSES.- It is especially found young people, and is usually due to general debility associated with overuse of the eyes; chronic blepharitis or conjunctivitis and exposure to cold winds may cause cause it.
TREATMENT.- We are not often called upon to prescribe for a single stye, but usually to prevent the recurrence of successive crops. If the case is seen at its very outset cold compresses or dry heat will sometimes abort the attack; though usually more benefit is derived especially after its commencement; from hot poultices.
If pus has formed, as shown by a yellow point, an incision should be made to permit its escape. If dependent as it frequently is, upon impairment of the general health, proper hygienic measures must be advised.
Pulsatilla.- This is an excellent remedy for styes of every description and in every stage of the disease. If given early, before the formation of pus, it will often cause them to abort; if used later, relief from the pain and hastening of the process of cure is frequently produced, while, as a remedy for the prevention of the recurrence of successive crops it is of great value. It is especially useful if dependent upon some gastric derangement, as from indulgence in high living fat food, etc. and if accompanied by acne of the face; also when found in amenorrhoeic females or the peculiar Pulsatilla temperament.
Hepar.- Indicated if suppuration has already commenced, with throbbing pain, great sensitiveness to touch and amelioration by warmth.
Rhus tox.- Useful in the early stages when there is an oedematous swelling of the lids especially if associated with conjunctivitis and profuse lachrymation. Graphites.- Useful in preventing the recurrence of styes. (Compare general symptoms of patient.)
Staphisagria.- Recurrence of styes, especially on the lower lid, which are inclined to abort and leave little hard nodules in the lids.
Sulphur.- To prevent the recurrence of successive crops, especially in a strumous diathesis, as shown by eruptions of the body. Cannot bear to have the eyes washed, and is restless and feverish at night.
Thuja.- Obstinate forms of styes which seem to resist treatment and form little hard modules on the margins of the lids.
The following remedies have also been recommended and used with advantage: Acon., Arsen., Calc., Caust., Con., Lyco., Merc, Pic. ac., Phosph. ac., and Silicea.
Ptosis is a drooping of the upper lid, due to either partial or complete paralysis of the levator palpebrae superioris. It may occur alone or be associated with a paralysis of the other muscles supplied by the third nerve, and is sometimes congenital. When complete, the upper lid covers nearly the whole of the cornea. The most frequent causes are syphilis, when of a central origin and trauma when peripheral. The so-called spurious ptosis is a drooping of the lid due to increased weight rather than to any diminished power of the levator muscle of the lid. This condition is found in thickening of the tissue from chronic trachoma from new growths, etc. Ptosis adiposa, a condition in which a relaxed fold of the skin hangs down like a pouch over the free border of the lid when it is raised also comes under this heading.
TREATMENT: Chief reliance must be placed upon internal medication though sometimes electricity proves of great value, either used alone or in connection with the indicated remedy. If the disease-dependent upon irremedial causes resists all treatment, operative measures must be resorted to.
Causticum.- More benefit has probably been derived from this remedy in the treatment of ptosis than from any other. Its special indication is drooping of the lid, resulting from exposure to cold ( Rhus, from damp cold). The symptoms in the provings very strongly point to Caust, as a remedy in this disorder, as "inclination to close the eyes; they close involuntarily. Sensation of heaviness in the upper lid as if could not raise it easily, " etc.
Rhus tox.- Especially if found in a rheumatic diathesis, and if the cause can be traced to working in the wet, getting the feet damp or to change in the weather. Heaviness and stiffness of the lids, like a paralysis, as if it were difficult to move them.
There may be aching, drawing pains in the head and face or they may be absent. The concomitant symptoms will point to its selection, though it has proved useful when none are present.
Alumina.- The upper lids are weak, seem to hang down as if paralyzed, especially the left. Burning dryness in the eyes, especially on looking up. Absence of lachrymation. Particularly useful for loss of power in the upper lids met with in old dry cases of granulations.
Euphrasia.- If caused from exposure to cold and wet and accompanied by catarrhal symptoms of the conjunctiva.
Ledum.- Ptosis resulting from an injury, with ecchymosis of the lids and conjunctiva.
Spigelia.- Ptosis, resulting from inflammation or other causes, times hot, scalding lachrymation accompanies the above.
Gelsemium Stannum and Conium have been favorably employed in this affection especially, the former. (Compare paralysis of the muscles.)
Many operative measures have been recommended for the relief of Ptosis. The old method was simply the removal of a portion of the skin and fibres of the orbicularis muscle, and this, in some cases of partial ptosis, may suffice.
Pagenstecher, in 1881, introduced the operation of inserting subcutaneous sutures, running from near the margin of the lid to the forehead above the brow, and tied tightly, expecting by the resulting cicatrices, as the sutures cut their way out, to raise the lid.
Wecker combines the operation of sutures with the old method of excision, as follows: He removes an elliptical portion of the skin and muscular fibres. He then inserts a strong thread above the brow running underneath the skin to the upper edge of the wound,over which it passes to the lower border of the wound and then pierces the skin near the free border of the lid; it is now carried parallel to the lid for about five millimetres, where the puncture is again made and it travels backward on a reverse course, parallel to its downward path, to the brow. The two ends are now tied together over a roll of plaster and tightened from time to time as they become loose (Figs. 31 and 32). Two such sutures are introduced. The wound is in this way closed, and, as the sutures cut through, cicatrices are formed which hold the lid up permanently.
In addition to the operations described, Birnbacher makes an operation to connect the tarsus with the frontalis by cicatrices. He passes three sutures through the upper border of the tarsus up under the skin and out in the eyebrow. Where they are tied over a roll of lint and left in place for three weeks. Panas endeavors to bring about a union between the lid and frontalis muscles by fastening a flap from the lid to the skin of the forehead. Eversbusch and Hugo Wolff both propose an operation for congenital ptosis to increase the power of the levator by advancing its insertion.
Blepharospasm.-Spasmodic closure of the lids, due to reflex irritation of the ophthalmic division of the fifth nerve, is often dependent upon some conjunctival irritation, or it may be due to a foreign body, an ulcer of the cornea, iritis, refractive errors, carious teeth, hysteria, or other reflex conditions. The spasm of the lid may be of the tonic variety, in which there is continued and complete closure of the lids, with perhaps an inversion of the eyelashes, which will of course cause great irritation of the eye. In obscure cases where no lesion of the eye itself can be found search should be made for "pressure points," i.e., a point upon some branch of the third nerve, or the supraorbital at the orbital notch; or it may be the infra- orbital, temporal, supramalar, inferior alveolar, or even some remote point along the course of some other nerve, that will stop the spasm.
TREATMENT- This should first be directed to the cause of the irritation, and, as it is usually dependent upon corneal troubles, is relieved with them. When however, it is independent of other affections remedies must be prescribed for the spasm per se.
Agaricus-Twitchings of the lids, with a feeling of heaviness in them, relieved during sleep and sometimes temporarily by washing in cold water. Spasms of the lids. It is very rare to meet a case of morbid nictitation which will not yield to this remedy. (Four-drop doses of the tincture two or three times a day will often relieve when the potencies fail.)
Other remedies which have proved useful in individual cases are Alumina, Cicuta, Ignatia, Nux v., Physos and Pulsat. Division of the affected nerve may be necessary in aggravated cases. The use of galvanism is often of great value in some cases-the positive pole is applied on any discoverable pressure point and the negative to the back of the neck. Canthomy, the division of the structures at the outer canthus by means of scissors, may be valuable in cases of tonic spasm.
Nictitatio-Constant blinking is frequently met with, especially in children and nervous, delicate persons. It is also sometimes present in exhaustion from excessive drinking, etc. This condition is generally due to some irritation in the eye itself, or may be reflex, from worms, decayed teeth, etc. Remove the cause, if determinable, and Agaricus will complete the cure.
Blepharophimosis-Narrowing of the palpebral opening from contraction of the skin of the lid is usually caused by chronic conjunctivitis, especially when flabbiness of the skin in old age favors such a formation and is relieved by canthotomy.
Symblepharon-Adhesion, partial or complete, of the eyelid to the eyeball. This condition occurs when, as the result of destruction of the mucous membrane from burns, as acids or lime, etc., or after diphtheritic or trachomatous conjunctivitis, two opposed portions of the conjunctiva grow together and may be either partial, when but one or more bands extend between the lid and globe, or complete, when the entire surface of the lid is attached, to the globe. The lower lid is most commonly adherent, and more or less limitations in the movements of the eye ensues. It may comprise the cul-de-sacs or the border of the lids (Fig- 33). The thickness of the adherent portions may vary, and we will have a sarcomatous, membranous or fibrinous symblepharon. Owing to the restrictions in the movement of the eye,and from the possible loss of vision due to its covering the pupil, every means must be tried to prevent adhesions in burns of the conjunctiva. To accomplish this the wounded surfaces must be separated daily during healing by some mechanical means, and the application of oil or vaseline to prevent their sticking together. The mucous membrane in these cases is destroyed to such an extent that simply dividing the adhesions will do no good, as they will at once grow together again. There are two methods of operating upon these cases with some prospect of success. First by separating the affected portions and inserting conjunctival flaps brought from neat by or from the opposite side of the cornea between them, or second, failing in this, to transplant from another person.
Ankyloblepharon is an adhesion of the ciliary margins of the eyelids. It may be complete or partial, often combined with symblepharon, and is acquired from burns or wounds, or congenital. The treatment is by inserting a grooved director behind the lids and dividing the adhesions, or, when extensive, by canthoplasty with sutures in the conjunctiva to present re-adhesion.
Lagophthalmos, is an incomplete closure of the palpebral fissure when the lids are shut together, and in the most cases there is inability to close the eyelids. It may result from a paralysis of the orbicularis, cicatrices in the skin of the lids, exophthalmos, staphyloma, etc. The danger of this condition is from ulceration of the cornea, due to its exposure to air and external irritants, owing to the inability to remove foreign substances by winking.
TREATMENT-In paralytic cases galvanism, with remedies directed to the cause of the paralysis ( such as syphilis, rheumatism, etc.) will often result in a cure. Cases that do not yield to this treatment require the operation of tarsorrhaphy to reduce the size of the opening of the eyelids.
Epicanthus is a congenital deformity in which a crescentic fold of skin projects in front of the inner canthus. It may also be seen in persons with flat noses, such as Mongolians, or syphilitics. As the child grows it disappears altogether, or becomes much less noticeable, so that operative interference is only called for in high degrees for cosmetic purposes. The operation is to remove an elliptical piece of skin from the bridge of the nose and uniting the edges of the wound together with sutures, care being taken to secure union by first intention by preventing any dragging on the stitches.
Trichiasis and Distichiasis- Where there is an irregularity in the shape and position of the eye-lashes so that they become curved in and in contact with the eye, it is called trichiasis, and where there is a double row of lashes, one of which is in contact with the eye, it is called distichiasis. Inverted cilia may affect part or the whole of the lid, and are usually thin pale or stunted. They cause more or less irritation of the eye, sometimes ulcers, pannus, etc., and are usually due to blepharitis, trachoma, injuries, burns, etc.
TREATMENT-Where there are but a few ingrowing lashes, epilation, if often repeated, may cause an atrophy of the hair bulbs and in this way cure the case (Fig.34 ). Electrolysis, as a curative measure, is most serviceable when the lashes to be destroyed are not too numerous. This is done by inserting a needle into the hair follicle and then connecting it with the negative pole of the battery, the positive being applied to the temple.
Arlt's operation, when modified to meet the emergencies of the case, seems to be the most generally advisable method of operating for the severe cases and is shown in the illustration (Fig.35). An incision two or three mm. in depth is made along the free border of the lid, splitting it into two layers.
A narrow strip of skin is then excised from the lid, cutting down to the first incision, as shown in the dotted lines in Fig. 35, so that the cilia remain in a bridge of tissue, which is shifted upward and its upper edge attached by sutures to the skin of the lid-its lower margin being left free. To avoid cicatricial contraction drawing the cilia down again, some transplant a narrow strip of the skin removed from the lid into the space that the gapes open in the free border of the lid.
Entropium is an inversion of the eyelid. We find two varieties of entropium; first the spastic, which is usually of the lower lid and is due to a spasmodic contraction of the orbicularis muscle. It is often met with in old people, sometimes coming on after operations, and is due to the lax condition of the skin. It may also be due to irritation from a foreign body, from keratitis, etc. The second variety of entropium is the cicatricial, which gradually comes on during the process of cicatrization and is the result of granular and diphtheritic conjunctivitis, burns, etc., where there has been loss of substance in the conjunctiva. Entropium results in much irritation and pain in the eye. From the continuous scratching of the cornea from the inverted lashes, ulcers and pannus finally ensue.
TREATMENT- In the spasmodic entropium a cure may often be effected by painting the parts with collodion, which should be renewed every two or three days, or oftener, in order to keep the lid in position. Adhesive strips may be applied for the same purpose. If these measures do not suffice, and always in the cicatricial entropium, operative interference must be resorted to before a cure can be made. Owing to the excessive vascularity of the lids, free haemorrhage occurs from any operation upon the lids unless controlled by the use of entropium forces (Fig. 36). There are various operations for the relief of entropium, of which perhaps Green's is the most serviceable in the majority of cases. This is made by everting the lid and making an incision from the conjunctival side, parallel to and about two mm. above its free border through the entire thickness of the tarsus, the incision to extend from one canthus to the other. A strip of skin about two mm. above the cilia is then removed.
Three sutures are then passed from the conjunctival side of the cilia through the free edge of the tarsus to just above the lower border of the skin wound; from there they pass through the muscular fibres on the outer surface of the tarsus and emerge from the skin about half an inch above the upper border of the wound. On lying these sutures the ciliary border is everted and the skin wound closed. Streatfeild's operation is the removal of a strip of skin with subjacent muscular fibres and a portion of the tarsus, just above the border of the lid, by cutting a deep V-shaped groove in its outer surface.
Other operations are Arlt's, already described, and those of Hotz, Snellen, Pope and others.
Remedies may possibly be useful, if the inversion is recent and only slight in degree. The following are suggested: Aconite, Argent. nit, Calc. and Natrum mur.
Ectropium is an eversion of the eyelids. The eversion may be slight or so great as to expose almost the whole of the palpebral conjunctiva. Ectropium is also divided into two classes, the spastic, due to chronic inflammation and swelling of the conjunctiva, which separates the lid margin from the eye, and this separation serves to increase the trouble by causing the tears to flow over the lid, which , in its turn by this irritation, aggravates the existing trouble. This form is also sometimes seen in children due to the swelling and inflammation of the conjunctiva, with contraction of the orbicularis. There is also in some cases a drooping of the lower lid from paralysis of the orbicularis, or from a defective innervation of this muscle in old people, which allows the tears to flow over the lid and cause ectropium. The cicatricial ectropium is due to a contraction after loss of the skin of the lids or of the face, following burns, wounds, abscesses, caries of the edge of the orbit with adhesions of the skin, etc. TREATMENT-In cases of spastic ectropium we may sometimes give relief by replacing the lid and retaining it there for several days by the use of the compress bandage. Scarification or removal of a strip of the conjunctiva to reduce the obstruction from thickening of the conjunctiva, together with the slitting up of the canaliculus, to permit the passage of the tears through the normal channels, may be tried. Other operations recommended to correct this affection are legion, and, as they must necessarily vary in nearly every case, according to the cause, degree and position of the eversion, but two will be detailed.
No plastic operations should be attempted until all tendency to contraction of the cicatrices has disappeared. In all flap operations allowance must be made for shrinking.
In Wharton Jones's operation a V-shaped (Fig.37) incision is made to include all the cicatricial tissue possible; the flap thus formed is to be dissected from the underlying tissues, and the skin at either side undermined sufficiently to allow of the lid being returned to its normal position. The exposed surface is then to be covered by bringing together the edges of the V- shaped wound with sutures so that it becomes Y-shaped(Fig.38)
Dieffenbach's operations is especially useful in the cicatricial form of ectropium and is made by dissecting away the diseased tissue by triangular incision. A flap of skin is then loosened by careful dissection from the immediate neighborhood and shifted up on the exposed surface, where it is kept in position by pins and sutures (See Figs. 39 and 40) The surface from which the flap was removed, if small, will become covered by growth of the integument from the edges of the wound; but, when large, it should be filled with grafts of skin from other parts of the body. The ectropium may also be corrected by skin grafting from other parts.
Apis-Is especially indicated in the first stage of this affection, in which the swelling of the conjunctiva is very great.
Argent nit-If the lids are swollen, inflamed, everted and the puncta lachrymalis very red and prominent. The discharge of tears and pus is profuse.
Hamamelis vir.-A dilute solution of "Pond's Extract" applied locally is said to have cured a case occurring during the course of a severe conjunctivitis.
Little reliance must be placed upon internal medication in either entropium or ectropium, as operative measures are almost invariably necessary, except occasionally in the first stage.
Molluscum Contagiosum is an affection of the sebaceous glands. It consists of small, round, umbilicated whitish prominences which may become inflamed and go on to suppuration. It is a hypertrophy of the gland and the tumor is composed of epithelial elements. The contents can often be pressed out through the depression at the summit of the tumor. For treatment see chalazion.
Xanthelasma is a hypertrophy of the sebaceous glands and a fatty degeneration of the connective tissue of the skin. They appear as yellowish patches, especially on the upper lid. lvins The Hahnemannian Monthly, December, 1897. reports a case cured in fifteen treatments by the galvanic current of five milliamperes applied for fifteen minutes at each sitting., He used a special pliable silver electrode, two rods, 3/32 of an inch in diameter, so adjusted as to be easily approached to contact or separated to two inches. These two electrode points, wet in salt water, were so separated as to bring one at each end of the patch, on the normal skin. They may be removed when small by excision, for cosmetic purposes. Excision of large patches in some cases might result in ectropium.
Milium are small, circular, white tumors. They are removed by incision and pressing out of the contents.
Papillomata (warts) are occasionally found upon the edge of the eyelid and upon the conjunctiva. They should be snipped off.
Dermoid cyst is congenital, and contains hair-follicles, hairs, connective tissue, fat, etc. It is generally situated at the outer angle of the orbit, develops slowly and causes but little inconvenience. It should be removed without rupturing the tumor, if possible.
Naevi are found on the eyelids and are similar in appearance to those occurring elsewhere. They are best removed by the galvano-puncture.
Chalazion (Meibomian or Tarsal Cyst)- Latest authorities seem to consider a chalazion as a granuloma in connection with a Meibomian gland, and not a mere retention cyst. There is, however, at the same time associated with it an inflammation of the larger than a good-sized pea; several may occur at the same time or they may recur in successive crops. It is hard and tense to the touch, and the skin is freely movable over it, but the tumor is adherent to the underlying tissues (Fig.41)
It develops slowly, causing to inconvenience for months. It may suppurate, and, when it does, it usually points on the conjunctiva.
TREATMENT-Excision, as a rule, is the most satisfactory treatment of tarsal tumors, providing there are only one or two. But as it is usually tedious and painful to remove entire a small solid tumor, we may substitute for excision, opening of the tumor, squeezing out its contents, and stirring up the sac with the point of a knife. The opening of a chalazion should always be through the conjunctiva if possible. It may have to he repeated several times, but as there will be little pain attending the operation, no objection will be made by the patient. After opening, I usually give Hepar low to promote absorption of the sac. In the case of cystic tumors the whole of the cyst wall should be removed; it may be destroyed by the use of seton, but removal with the knife is usually more satisfactory. Many cases have been cured by internal medication alone, and remedies should always be employed, whether the knife is used or not, for they no doubt hasten the cure and serve to prevent recurrence. Staphisagria-An important remedy for tumors of the lid. It is my custom to apply the tincture externally at the same time the remedy is being taken in potency. Enlargement of the glands of the lids, which are red and accompanied by tensive tearing pains, especially in the evening. For little induration of the lids, resulting from styles, or for successive crops of small tarsal tumors, this drug is especially indicated.
Thuja-This is one of the most valuable remedies for tarsal tumors, whether single or multiple, especially if they appear like a condyloma, either of the internal or external surface of the lid. We have seen them disappear by simply giving the drug internally, though it usually seems to act more speedily if we use, at the same time, the tincture externally. It is also recommended for the prevention of their return after removal by the knife. For condylomata, or warty excrescences on the lids, especially if occurring in syphilitic subjects, this drug deserves attention.
Hepar-Tarsal tumors that have become inflamed and are sensitive to touch. It also aids absorption after operation.
Calcarea carb.- Tarsal tumors occurring in fat, flabby subjects.
Causticum-Tumors, especially warts, found on the lids and eyebrows.
Conium-Induration of the lids remaining after inflammation. Pulsatilla-Tarsal tumors of recent origin that are subject to inflammation, or are accompanied by catarrhal conditions of the eye. The temperament and general symptoms will decide the case.
Zincum-Tumors of the lids with soreness and itching in the internal canthi.
Baryta car, and iod., Graph., Lyco., Kali iod., Merc.,Nitric acid, Sep., Sil. and Sulph. may be required.
Epithelioma is the most frequent malignant growth affecting the eyelid. It rarely occurs before the age of forty, and appears first as small hard nodules, and later becomes covered with a scab, which, on being removed, shows a slight excoriation; this increases to an ulceration of considerable depth, with purulent secretion and irregular, hardened edges. It may remain indolent for months, then assume an active stage, leading rapidly to extensive destruction of tissue. In the early stage there is little or no pain, but becomes excessively painful in the later stages.
Epithelioma, lupus and chancre have a very similar general appearance.
DIFFERENTIAL DIAGNOSIS.
Epithelioma.
Indurated irregular edges.Slow growth.Attacks middle-aged and elderly people.
Lymph glands of neck involved late. Lupus.
Less induration. More inflamed.Growth slower than epithelioma Lymph glands involved late. Generally associated with lupus elsewhere in body.
Chancre.
Indurated, but edges more rounded. Rapid growth. Usually in younger subjects. Lymph glands early involved.Other symptoms of syphilis.
Lupus and Sarcoma have both been found affecting the eyelids. A lupoid growth is more slow in development than an epithelioma, and both may result in ulceration; but as Noyes Diseases of the Eye, 1890. so well says, "A discrimination between them is hardly needful for practical purposes."
TREATMENT-Excision is advised in all malignant growths of the lids, if the disease is circumscribed and moderate in extent; care being taken that all the morbid tissue is removed. The edges of the wound may be brought together by sutures, or a plastic operation may be made, bringing the integument from the temple or some adjoining point.
Juler 2 Ophthalmic Science and Practice, 1884. advises scraping away all the diseased tissue by means of a small steel scoop. This is attended with considerable haemorrhage and is tedious, but he claims its success in arresting this malignant affection is marvellous.
Various caustics have been employed, chief among which may be mentioned caustic potash, nitrate of silver, chloride of zinc, arsenic paste and acetic acid. An objection to the use of caustics lies in the deformity apt to occur afterward. Electrolysis has been recommended.
If the disease is very extensive, involving the tissues of the face to such an extent that extirpation is impracticable, we then rely chiefly upon our internal remedies, using only such local applications as prove agreeable and of temporary relief to the patient. For instance, if the discharge is profuse and offensive, a weak solution of carbolic acid, salicylic acid, or some other disinfectant proves of service. An application from which we have often seen excellent results is carbolic acid and linseed oil (4 grains to the ounce): it relieves the patient and seems to exert a beneficial effect over the progress of the disease.
Iodoform-Dr.George A.Shepard reports surprising results in two cases of lupus from the administration of this drug in the third decimal trituration.
Apis-Lupus non-exedens, sharp, stinging pains, and tendency toward puffiness of the lower lids. Hydrocotyle asiatica-Has obtained a high reputation in the hands of Dr. Boileau as a remedy for lupus and deserves our attention.
Phytolacca dec-Benefit seems to have been derived in relieving, if not curing, malignant ulcers of the lids, when used both externally and internally.
Thuja-Epithelioma of the lids.
Syphilitic Ulcers, Chancre, and Gummata are all occasionally found on the eyelids, and should be treated the same as occurring elsewhere. The most useful remedies are the following prescribed according to general indications: Ars., Apis., Aurum Cannab, Hepar, Kali iod., Merc., Nitric ac., and Thuja.
Herpes Zoster Ophthalmicus commences with severe neuralgic pains along the supraorbital division of the fifth nerve of one side, sometimes the nasal and rarely the infra-orbital branch of the same nerve. The skin becomes swollen and red, covered with herpetic vesicles which unite, crusts form upon them, followed by ulcerations which ultimately leave deep cicatrices. The cause of the disease is probably an inflammation of the nerve and the Gasserian ganglion belonging to it. The disease involves one-half of the face, never extending beyond the median line, and has often associated with it corneal ulcers and iritis. The intense pain that precedes the herpetic eruption may last for a few hours, or extend over months, but usually subsides with the appearance of the vesicles. TREATMENT-the remedies most useful are; Ars., Croton tig., Electricity, Canth., Graph. Merc, Puls, Ranunc., bulb and Rhus.
Contusions are very often found, and are frequently accompanied by some lesion of the globe on orbit.
TREATMENT-Immediately after contused wounds of the lids, cold compresses should be employed; they should be applied with a firm bandage, which often proves of advantage in limiting the amount of ecchymosis.
Arnica, our great remedy for all contusions, deserves its extensive reputation for curing "black eyes," as there is no other drug better adapted to this condition. A solution of the tincture in water, ten drops to the ounce, is usually employed, though both stronger and weaker solutions are in vogue. Ledum, used in the same manner, has also proved of service.
Wounds- We may have an incised, lacerated, or penetrating wound of the lid; and, in all cases, the condition of the orbit and globe should be carefully examined to see if they remain intact.
TREATMENT-The first object in view should be to bring together the edges of the wound by means of sutures, adhesive strips or collodion. If the wound is incised, without any contusion, and the edges are early brought accurately together, a dry dressing will often be found most beneficial.
Hamamelis and Ledum have both been recommended for wounds of the lids.
Burns and Scalds must be treated as usual in other parts of the body, except that care should be taken to prevent the union of the lids (ankyloblepharon) by frequently opening them, and by inunction of the edges with simple-cerate or cosmoline; also, great attention should be paid to the prevention of a cicatrix (which causes ectropium) by keeping the skin on the stretch by a bandage during the period of cicatrization. Cosmoline is especially recommended as an external application.
When dependent upon the stings of insects, the sting should be removed and cold water dressings applied.
Anatomy.- The eyelids form the external covering of the eyeballs and serve to protect the eye from injury both from excessive light and foreign substances; they also serve at the same time to distribute to the eyes the moisture secreted by the various glands.
The eyelids or palpebrae, are two thin movable folds, the upper being the larger and more movable of the two; their movement is both voluntary and involuntary, the latter action being due to the orbicularis muscle. The opening of the lids is chiefly by the action of the levator palpebrae superiors lifting the upper lid; when opened an elliptical space is left between the margins of the lids; this opening varies greatly, being larger in prominent eyes than in sunken ones and greater when looking upward. The angles of junction of the upper and lower lids are called canthi the outer canthus is more acute than the inner; near the extremity of the inner canthus is found on both the upper and lower lids a slight elevation, the apex of which is pierced by a small orifice, the punctum lachrymale, the commencement of the small channel or canaliculus leading to the tear sac.
The eyelids are composed of four layers, arranged from without inward in the following order, the integument, a layer of muscular fibres, the tarsus or as often erroneously called the tarsal cartilage, and the conjunctiva. The integument, which is extremely thin but similar in every other respect to the integument elsewhere, becomes at the margin of the lids, conjunctiva. The integument which is extremely thin but similar in every other respect to the integument elsewhere becomes, at the margin of the lids, continuous with the conjunctiva. Beneath the skin the connective tissue is loose and contains no fat.
The muscular fibres consist of the orbicularis palpebrarum a large flat, voluntary muscle extending over the orbital margins above and below and terminating by tendinous attachments at the angles of the lids, the tendons, together with some fibres of the muscle, being inserted in the adjacent bony wall. The fibres of the orbicularis which lie upon the tarsi are paler than the others, and certain bundles of these give to the lid its involuntary action are known as the ciliary muscles of Riolani. The orbicularis is somewhat adherent to the skin, but glides loosely over the tarsus. It receives its nerve supply from the facial. Its fibres being more or less circular in arrangement, and acting as a sphincter serve to close the eyes.
The levator palpebrae superioris arises at the apex of the orbit, and passing along its upper wall becomes intermingled in front of the tarsus with the orbicularis; other fibres become attached to the upper edge of the tarsus,and still others go to the conjunctiva. This muscle is supplied by a branch from the third nerve and its action, is as its name implies, to raise the upper lid. The lower lid is supplied with a prolongation from the inferior rectus, whose insertion and action is analogous to that of the levator palpebrae.
The tarsi are two thin, elongated plates composed of condensed fibrous tissue, and serve to form the framework of the lids; they are united to each other and to the adjacent bone through the medium of the internal and external lateral ligaments.
The conjunctiva is a delicate mucous membrane which commences at the free border of the lid where it is continuous with the skin; it lines the inner surface of the lids and is then reflected upon the globe, over which it passes and becomes continuous with the cornea. The palpebral portion is thicker and more vascular than that covering the globe and is firmly attached to the tarsus. Where it passes from the lids to the globe it is thin and loose, and forms what are called the fornix conjunctiva. The plica semilunaris is a vertical fold of conjunctiva at the inner canthus, and the reddish elevation at the inner angles is called the caruncula lachrymalis.
The cilia are short, thick, curved hairs, arranged in double or triple rows at the margins of the lids; their follicles are surrounded by sebaceous glands and the glands of Moll. Within the tarsus are embedded the Meibomian glands, which in structure resemble the sebaceous glands. These various glands by their secretions serve to lubricate the eye, and discharge their secretion through excretory ducts opening by minute orifices upon the free border of the lids between the rows of cilia.
Blepharitis._ (Blepharitis Simplex, Blepharo-Adenitis, Blepharitis Ciliaris, Blepharitis Marginalis, Seborrhoea; Blepharitis Ulcerosa, Blepharitis Hypertrophica or Squamosa) Under this general heading inflammation of the lids, we shall group the various clinical sub-divisions. The numerous names (of which the above are but few) that have been given to an inflammation involving the border of the eyelids may be all grouped under two headings-non-ulcerative and ulcerative blepharitis.
SYMPTOMS.- The non-ulcerative form commences as a simple hyperaemia of the lid-border, which gives to the lids a red, swollen appearance. This is accompanied by a slight burning and smarting in the eyelids which is aggravated by cold winds, smoke, dust, exposure to bright light or use of the eyes at close work. There is agglutination of the eyelids in the morning, with dry scales or scabs adhering to the margins of the lids and more or less photophobia and lachrymation are present. This variety depends upon an abnormal secretion of the sebaceous glands.
The ulcerative variety may be considered as an extension of the preceding form. If we remove with the forceps the yellow crusts surrounding and embedding the cilia which have formed through neglect in the previous stage we find a red, bleeding ulcerative surface. This surface to secrete pus that forms other crusts, and by extension of the ulceration the entire edge of the lid may become involved. At this stage the disease is know as blepharitis ulcerosa, and as it advances the edge of the lid not only becomes red and covered with scales, but considerably thickened, and it is then termed blepharitis hypertrophica. It the disease still continues unchecked it involves the hair follicles and causes the lashes to become stunted and misplaced (trichiasis), or to fall out, and when entirely wanting we have the condition known as (medarosis). The final stage of the disease is when the lid itself becomes rounded, red, thickened, everted and deprived of lashes (lippitudo).
COURSE.- The course of the disease is usually very chronic and yet should be cured by thorough and prolonged treatment.
CAUSES: The disease is especially the result of refractive errors in young, delicate persons of a strumous diathesis. As the causes are so closely associated with the treatment, they will be considered further under that heading.
TREATMENT.- First, we should examine the refraction and if any error is found, correct the same with the proper glass as in many cases this alone will cure the entire trouble.
In rare cases the presence of lice on the eyelashes may be the exciting cause (phthiriasis ciliarum), when we should be careful to remove them and apply either cosmoline or some mercurial ointment, which will destroy them and prevent their recurrence.
Fungous growths in the hair follicles are also said to cause this disease, in which case the hairs should be extirpated, and either external or internal medication employed.
Another cause is frequently found in affections of the lachrymal canal, particularly catarrh of the lachrymal sac and stricture of the duct; in these cases the tears, being hindered from flowing through their natural passage into the nose collect in the eye, flow over the lids and down the cheek; thus the retention of the tears will cause an inflammation of the margins and eventually of the whole structure of the lids. Any other affection which will have the same result (flowing of the tears over the lids) will of course, produce the same trouble and this is often found in slight degrees of eversion of the lower lids (ectropium), which displaces the puncta lachrymalis and thus prevents the tears from passing into the sac. In all such cases the first thing to be done is to open the canaliculus into the sac, and, if necessary, the nasal duct into the nose so as to give a free passage for the tears into that organs, after which the treatment is the same as in uncomplicated cases.
But the most common causes of ciliary blepharitis are exposure to wind, dust, smoke etc., especially when complicated with want of cleanliness; it is for this reason we see this trouble so frequently among the poorer classes. As it is upon this point-cleanliness -that the success of our treatment depends to a great extent, we should impress upon the patient is mind the necessity of it in terms as forcible as possible.
They should be directed to remove the scales or crusts from the margins of the lids as soon as formed, not allowing them to remain even a few minutes. This should not be done by rubbing, as the patient is inclined to do on account of the itching sensation, for by so doing excoriations are made, lymph is thrown out and new scabs form, which only aggravate the inflammation. But they should be directed to moisten the crusts in warm water and then carefully remove them with piece of fine linen or by drawing the cilia between the thumb and fingers; at the same time gentle traction may be made on the lashes, so as to remove all that are loose as they act only as foreign bodies. Sometimes the scabs are so thick and firm that moistening in warm water is not sufficient to remove them; in such cases, hot compresses or poultices should be applied for ten or twenty minutes at a time until they can be easily taken away.
In the treatment of chronic inflammation of the margins of the lids, external application are of great value and without their use a cure is often impossible. It is true that a careful attention to cleanliness, together with the internal administration of the indicated remedy, will cure a large proportion of the cases but the duration of treatment will be usually much longer than if we employ local means at the same time we give internal remedies.
Cosmoline or Vaseline.- This unguent has been of great service in the treatment of blepharitis. It may be used alone or to form a base for the administration of other remedies. It prevents the formation of new scales and the agglutination of the lids, besides seeming to exert a beneficial influence over the progress of the disease. This, like all other ointments, should be used once or twice a day, or even oftener if the case is very severe. All scales or crusts should be carefully removed; after which a very little of the ointment may be applied to the edge of the lids with the finger or a camel's hair brush. The smallest amount possible, to oil the ciliary margins of the lids should be applied, as aggravation of the inflammation may result from its too free use.
Mercury.- For years this has been a favorite local application in blepharitis. It seems to be better adapted to the severe forms of inflammation of the lids than Graphites, for there, is more redness, more swelling, more secretion and more tendency toward ulceration. The two following prescriptions have been employed with the most favorable results, especially the yellow oxide:
Rx. Hydrarg oxyd. flav., ..............gr. ij.
Vaseline, ..........................3 ij.
Misce.
Rx. Liq. Hydrarg nitr...................gtt. iij.
Vaseline, ..........................3 ij.
Misce.
In some cases more of the mercury is used, in others less according to the severity of the symptoms.
Grapho-Vaseline- Graphites, as will be seen in the symptomatology, is more commonly indicated in blepharitis than any other one remedy. Many cures have resulted from its internal administration alone, when indicated but more brilliant results may be obtained by employing at the same time locally the following unguentum.
Rx Graphites......................... gr.ij Vaseline, ......................... 3ij
Misce.
Various other ointments and washes have been used with variable success. The use of milk cream, lard and simple cerate, to prevent the lids from sticking together have also been of aid with internal medication.
Graphites.- This in one of the most important remedies we possess for the chronic form of this disease, though it may be indicated in acute attacks, especially if complicated with ulcers or pustules on the cornea. Particularly useful if the inflammation occurs in scrofulous subjects covered with eczematous eruptions, chiefly on the head and behind the ears; which are moist fissured and bleed easily. The edges of the lids are slightly swollen, of a pale red color and covered with dry scales or scurfs or the margins may be ulcerated. The inflammation may be confined to the canthi especially the outer, which have a great tendency to crack and bleed upon any attempt to open the lids. Burning and dryness of the lids are often present, also biting and itching causing a constant desire to rub them. It is important in eczema of the lids if the eruption is moist with tendency to crack while the margins are covered with scales or crusts.
Mercurius sol.- Very favorable results have been gained by this remedy in blepharitis, especially if dependent upon or found in a syphilitic subject or if caused from working over fires or forges. The lids are thick red, swollen and ulcerated (particularly the upper) and sensitive to heat or cold and to touch. Profuse acrid lachrymation is usually present which makes the lids sore, red and painful, especially worse in the open air or by the constant application of cold water. All the symptoms are worse in the evening after going to bed and from warmth in general, also from the glare of a fire or any artificial light. The concomitant symptoms should receive special attention as excoriation of the nose from the acrid coryza, flabby condition of the tongue, nocturnal pains etc.
Hepar Sulph.- The is the remedy most frequently employed in acute phlegmonous inflammation, especially after the first stage has passed and suppuration is about to, or has already taken place. The lids are inflamed, as if erysipelas had invaded them, with throbbing, aching, stinging pains, and very sensitive to touch; the pains are aggravated by cold and from contact, but ameliorated by warmth. It may also be useful in certain forms of blepharitis in which the lids are inflamed sore and corroded, as if eaten out or if small red swellings are found along the margins of the lids, which are painful in the evening and upon touch. There is general amelioration from warmth. Often called for when the Meibomian glands are thick and honeycombed in character on and around the lids, it is very valuable.
Pulsatilla.- Blepharitis, both acute and chronic especially if the glands of the lids are affected (blepharo-adenitis) or when there is a great tendency to the formation of styes or abscesses on the margin of the palpebrae. Blepharitis resulting from high living or fat food and when accompanied by acne of the face; also in cases in which the lachrymal passages are involved. The swelling, redness and discharges vary, though the latter are more often profuse and bland, causing agglutination of the lids in the morning. Itching and burning are the chief sensations experienced. The symptoms are usually aggravated in the evening in a warm room or in a cold draught of air, but ameliorated in the cool open air.
Calcarea carb.- Blepharitis occurring in persons inclined to grow fat, or in unhealthy "pot-bellied" children of a scrofulous diathesis who sweat much about the head. The lids are red, swollen and indurated. Inflammation of the margins of the lids, causing loss of the eyelashes, with thick, purulent excoriating discharge and burning, sticking pains. Great itching and burning of the margins of the lids, particularly at the canthi; throbbing pain in the lids. Most of the eye symptoms are worse in the morning, on moving the eyes and in damp weather. Great reliance should be placed on the general cachexia of the patient.
Calcarea iod.- Seems to act better than the carbonate in blepharitis found in those unhealthy children afflicted with enlargement of the glands and especially of the tonsils.
Rhus tox.- Its chief use is in acute phlegmonous inflammation of the lids and erysipelas; lids oedematously swollen (especially the upper) and accompanied by profuse lachrymation; there may be erysipelatous swelling of the lids, with vesicles on the skin; chemosis is often present. The pains are worse at night, and in cold, damp weather but relieved by warm application. It may be of service in acute aggravations of chronic inflammation from exposure in wet weather or when worse at that time, with much swelling of lids and profuse lachrymation.
Mezereum.- Blepharitis accompanied by tinea capitis; or eczema of the lids and head, characterized by thick hard scabs, from under which pus exudes on pressure.
Antimonium crud.- Obstinate cases in which the lids are red, swollen and moist with pustules on the face. Especially in cross children. Pustules on the ciliary margins.
Arsenicum.- Inflammation of the margins of the lids, which are thick, red and excoriated by the burning, acrid lachrymation. The cheek may also be excoriated. The lids are sometimes oedematously swollen and spasmodically closed, especially when the cornea is at the same time affected. The characteristic burning pains are important and usually present. The general condition of the patient decides us in the selection, as the great prostration, restlessness, aggravation after midnight and thirst are commonly seen in scrofulous children. Often useful in the early stages of abscess of the lids.
Sulphur.- A remedy called for especially in the chronic form of this disease and when found in children of a strumous diathesis who are irritable and cross by day and restless and feverish by night; also for blepharitis appearing after the suppression of an eruption or when the patient is covered with eczema. The lids are red, swollen and agglutinated in the morning or there may be numerous small itching pustules on the margins. The pains are usually of a sticking character though we may have itching, biting, burning and a variety of other sensations in the lids. There is generally great aversion to water so that they cannot bear to have the eyes washed. Eczematous affections of the lids, like eczema in other portions of the body, which indicate Sulphur, are often controlled.
Psorinum.- Old chronic cases of inflammation of the lids especially when subject to occasional exacerbations. It has also been of service in the acute variety when the internal surface of the lids was chiefly affected with considerable photophobia. Particularly indicated in a strumous diathesis with unhealthy, offensive discharges from the eyes.
Aconite.- Chiefly called for in the acute variety of this trouble especially when caused from exposure to cold dry winds and in the very first stage of abscess. The lids-especially the upper - are red and swollen with a tight feeling in them, while great heat, dryness, burning and sensitiveness to air are present; the dry heat is temporarily relieved by cold water. The conjunctiva is usually implicated.
Alumina.- Chronic inflammation of the lids (particularly if complicated with granulations) characterized by burning and dryness of the lids especially in the evenings; itching dryness, and excoriation at the canthi. Absence of lachrymation. There is not usually much destruction of tissue not great thickening of the lids.
Apis mel.- Incipient stage of abscess before the formation of pus, if there is great puffiness of the lids, especially of the upper with stinging pains. Much reddish-blue swelling of the lids; temporary relief from cold water. There is often chemosis and the lachrymation is profuse, hot and burning (Rhus), though not acrid, as under Arsenicum. Drowsiness and absence of thirst are often present.
Argentum nit.- Lids sore, very red and swollen especially when complicated with granular conjunctivitis or some other external trouble. There is usually profuse discharge from the eyes, causing firm agglutination in the morning. The symptoms are often relieved in the cold air, or by cold application and may be associated with headache, pain in the root of nose, etc.
Aurum.- Rarely useful in uncomplicated blepharitis, except when occurring in scrofulous or syphilitic subjects, after the abuse of Mercury. The lids may be red and ulcerated, with stinging, pricking or itching pain in them. Cilia rapidly fall out.
Causticum.- Blepharitis, with warts on the eyebrows and lids. The symptoms are ameliorated in the open air. Feeling of sand in the eye.
Chamomilla.- Of benefit as an intercurrent remedy, even if it does not complete the cure, in cross, peevish children who want to be carried. The local symptoms are not marked,
Cinnabaris.- Ciliary blepharitis, with dull pain over or around the eye. There may be dryness of the eye, or considerable discharge. Croton tig.- When there is complicated with the blepharitis a vesicular eruption on the lids and face.
Euphrasia.- A valuable remedy if the lids are red, swollen and excoriated by the profuse, acrid, muco-purulent discharge, or even if ulcerated. The lachrymation is also profuse, acrid and burning; often accompanied by fluent coryza. The cheek around the eye is usually sore and red from the nature of the discharges.
Mercurius Corr.- This from of Mercury differs very little in its symptomatology from the solubis, and that is chiefly in degree, as the pains are generally more severe and spasmodic in character, lachrymation more profuse and acrid, secretions thinner and more excoriating and inflammatory swelling greater than in any other preparation. It has proved curative in inflammatory swelling of indurated lids; inflammatory swelling of cheeks and parts around the orbits which are covered with small pustules and especially in scrofulous inflammation present.
Natrum mur.- Ciliary blepharitis, particularly if caused by the use of caustics (nitrate of silver). The lids are thick and inflamed, smart and burn, with a feeling of sand in the eye. The lachrymation is acrid, excoriating the lids and cheeks, making them glossy and shining; often accompanied by eczema.
Nux-vom.- Chronic inflammation of the lids,with smarting and dryness, especially worse in the morning. It is particularly indicated in blepharitis dependent upon gastric disturbances.
Petroleum.- Has been of benefit in blepharitis, especially if combined with the use of cosmoline externally. Great reliance should be placed on the occipital headache, rough skin, etc., generally found when this drug is indicated, though it has been used with advantage when no marked symptoms were present.
Sepia.- Chronic inflammation of the edges of the lids with scales on the cilia and small pustules on the lid margins (acne ciliaris). Feeling as if the lids were two heavy or as if they were too tight and did not cover the ball. Worse morning and evening.
Silicea.- Blepharitis from working in a damp place or being in the cold air. (Calc., Rhus.) Indicated in abscesses, after suppuration has commenced. Silicea is more particularly called for in the carbuncular form and especially if the patient is very nervous and the local symptoms are accompanied by sharp pains in the head, relieved by wrapping up warm.
Staphisagria.- Bleeding in which the margins of the lids are dry, with hard nodules on the borders and destruction of the hair follicles. Itching of the lids.
Tellurium.- Eczema of the lids especially if complicated with a moist eruption behind the ears and offensive otorrhoea smelling like fish brine.
In addition to the above, the following remedies have also proved serviceable: Lycop., Merc., nitr., Merc. prot., Sang., Senega. Abscess of the Lid.- (Phlegmon, Furuncle).- Suppuration in the connective tissue of the lid is generally the result of trauma, and is then due to a breaking down of the blood-clot formed at the time of the contusion. It may also follow debilitating diseases, or be associated with adenitis in scrofulous children. There will be great swelling of the lid, with more or less heat, redness and pain. Fluctuation maybe detected early and inflammation of the conjunctiva is apt to be associated with this disease. General inflammation of the lid may sometimes be seen in children without suppuration; while in cachectic subjects we may have a gangrenous condition. Furuncle differs from abscess or phlegmon, in that it is less diffuse, less evidence of fluctuation and more necrosis of tissue.
TREATMENT.- By a careful selection of our remedy in the first stage, we can often cause the inflammation to subside before suppuration has taken place. It is also possible to promote the resolution and discharge of pus already formed. Cold (iced) application are recommended if the disease is seen at the outset; but if we suspect that the formation of pus has commenced,a change to hot applications (poultices) should be made.
As soon as fluctuation can be felt, a free incision into the swelling parallel to the margin of the lids should be made in order to give free vent to the confined pus. After the escape of the pus, warm application of Calendula and water (ten drops to the ounce) are advised. A compress bandage should also be employed if the abscess is extensive, so as to keep the lid in position and the walls of the abscess in contact and thus hasten the union.
If it has already spontaneously opened, the perforation should be enlarged if it be insufficient and unfavorably situated; also if there be several apertures, they should be united by an incision, in order to leave as small a cicatrix as possible. A generous diet should be prescribed. For remedies, see blepharitis page 107.
Hordeolum (Stye, Acne). Is an acute inflammation of the cellular tissue of the lid leading to suppuration and pointing at the edge of the lid. The location of the inflammation is usually in the tissue surrounding a hair follicle.
SYMPTOMS.- At first it appears as a hard circumscribed redness and swelling which frequently extends so that the whole lid will become oedematously swollen. There is at first much severe throbbing pain. Occasionally there are two or more at the same time, and they often occur in successive crops.
COURSE.- They usually point and break in three or four days, though they may undergo absorption without breaking.
CAUSES.- It is especially found young people, and is usually due to general debility associated with overuse of the eyes; chronic blepharitis or conjunctivitis and exposure to cold winds may cause cause it.
TREATMENT.- We are not often called upon to prescribe for a single stye, but usually to prevent the recurrence of successive crops. If the case is seen at its very outset cold compresses or dry heat will sometimes abort the attack; though usually more benefit is derived especially after its commencement; from hot poultices.
If pus has formed, as shown by a yellow point, an incision should be made to permit its escape. If dependent as it frequently is, upon impairment of the general health, proper hygienic measures must be advised.
Pulsatilla.- This is an excellent remedy for styes of every description and in every stage of the disease. If given early, before the formation of pus, it will often cause them to abort; if used later, relief from the pain and hastening of the process of cure is frequently produced, while, as a remedy for the prevention of the recurrence of successive crops it is of great value. It is especially useful if dependent upon some gastric derangement, as from indulgence in high living fat food, etc. and if accompanied by acne of the face; also when found in amenorrhoeic females or the peculiar Pulsatilla temperament.
Hepar.- Indicated if suppuration has already commenced, with throbbing pain, great sensitiveness to touch and amelioration by warmth.
Rhus tox.- Useful in the early stages when there is an oedematous swelling of the lids especially if associated with conjunctivitis and profuse lachrymation. Graphites.- Useful in preventing the recurrence of styes. (Compare general symptoms of patient.)
Staphisagria.- Recurrence of styes, especially on the lower lid, which are inclined to abort and leave little hard nodules in the lids.
Sulphur.- To prevent the recurrence of successive crops, especially in a strumous diathesis, as shown by eruptions of the body. Cannot bear to have the eyes washed, and is restless and feverish at night.
Thuja.- Obstinate forms of styes which seem to resist treatment and form little hard modules on the margins of the lids.
The following remedies have also been recommended and used with advantage: Acon., Arsen., Calc., Caust., Con., Lyco., Merc, Pic. ac., Phosph. ac., and Silicea.
Ptosis is a drooping of the upper lid, due to either partial or complete paralysis of the levator palpebrae superioris. It may occur alone or be associated with a paralysis of the other muscles supplied by the third nerve, and is sometimes congenital. When complete, the upper lid covers nearly the whole of the cornea. The most frequent causes are syphilis, when of a central origin and trauma when peripheral. The so-called spurious ptosis is a drooping of the lid due to increased weight rather than to any diminished power of the levator muscle of the lid. This condition is found in thickening of the tissue from chronic trachoma from new growths, etc. Ptosis adiposa, a condition in which a relaxed fold of the skin hangs down like a pouch over the free border of the lid when it is raised also comes under this heading.
TREATMENT: Chief reliance must be placed upon internal medication though sometimes electricity proves of great value, either used alone or in connection with the indicated remedy. If the disease-dependent upon irremedial causes resists all treatment, operative measures must be resorted to.
Causticum.- More benefit has probably been derived from this remedy in the treatment of ptosis than from any other. Its special indication is drooping of the lid, resulting from exposure to cold ( Rhus, from damp cold). The symptoms in the provings very strongly point to Caust, as a remedy in this disorder, as "inclination to close the eyes; they close involuntarily. Sensation of heaviness in the upper lid as if could not raise it easily, " etc.
Rhus tox.- Especially if found in a rheumatic diathesis, and if the cause can be traced to working in the wet, getting the feet damp or to change in the weather. Heaviness and stiffness of the lids, like a paralysis, as if it were difficult to move them.
There may be aching, drawing pains in the head and face or they may be absent. The concomitant symptoms will point to its selection, though it has proved useful when none are present.
Alumina.- The upper lids are weak, seem to hang down as if paralyzed, especially the left. Burning dryness in the eyes, especially on looking up. Absence of lachrymation. Particularly useful for loss of power in the upper lids met with in old dry cases of granulations.
Euphrasia.- If caused from exposure to cold and wet and accompanied by catarrhal symptoms of the conjunctiva.
Ledum.- Ptosis resulting from an injury, with ecchymosis of the lids and conjunctiva.
Spigelia.- Ptosis, resulting from inflammation or other causes, times hot, scalding lachrymation accompanies the above.
Gelsemium Stannum and Conium have been favorably employed in this affection especially, the former. (Compare paralysis of the muscles.)
Many operative measures have been recommended for the relief of Ptosis. The old method was simply the removal of a portion of the skin and fibres of the orbicularis muscle, and this, in some cases of partial ptosis, may suffice.
Pagenstecher, in 1881, introduced the operation of inserting subcutaneous sutures, running from near the margin of the lid to the forehead above the brow, and tied tightly, expecting by the resulting cicatrices, as the sutures cut their way out, to raise the lid.
Wecker combines the operation of sutures with the old method of excision, as follows: He removes an elliptical portion of the skin and muscular fibres. He then inserts a strong thread above the brow running underneath the skin to the upper edge of the wound,over which it passes to the lower border of the wound and then pierces the skin near the free border of the lid; it is now carried parallel to the lid for about five millimetres, where the puncture is again made and it travels backward on a reverse course, parallel to its downward path, to the brow. The two ends are now tied together over a roll of plaster and tightened from time to time as they become loose (Figs. 31 and 32). Two such sutures are introduced. The wound is in this way closed, and, as the sutures cut through, cicatrices are formed which hold the lid up permanently.
In addition to the operations described, Birnbacher makes an operation to connect the tarsus with the frontalis by cicatrices. He passes three sutures through the upper border of the tarsus up under the skin and out in the eyebrow. Where they are tied over a roll of lint and left in place for three weeks. Panas endeavors to bring about a union between the lid and frontalis muscles by fastening a flap from the lid to the skin of the forehead. Eversbusch and Hugo Wolff both propose an operation for congenital ptosis to increase the power of the levator by advancing its insertion.
Blepharospasm.-Spasmodic closure of the lids, due to reflex irritation of the ophthalmic division of the fifth nerve, is often dependent upon some conjunctival irritation, or it may be due to a foreign body, an ulcer of the cornea, iritis, refractive errors, carious teeth, hysteria, or other reflex conditions. The spasm of the lid may be of the tonic variety, in which there is continued and complete closure of the lids, with perhaps an inversion of the eyelashes, which will of course cause great irritation of the eye. In obscure cases where no lesion of the eye itself can be found search should be made for "pressure points," i.e., a point upon some branch of the third nerve, or the supraorbital at the orbital notch; or it may be the infra- orbital, temporal, supramalar, inferior alveolar, or even some remote point along the course of some other nerve, that will stop the spasm.
TREATMENT- This should first be directed to the cause of the irritation, and, as it is usually dependent upon corneal troubles, is relieved with them. When however, it is independent of other affections remedies must be prescribed for the spasm per se.
Agaricus-Twitchings of the lids, with a feeling of heaviness in them, relieved during sleep and sometimes temporarily by washing in cold water. Spasms of the lids. It is very rare to meet a case of morbid nictitation which will not yield to this remedy. (Four-drop doses of the tincture two or three times a day will often relieve when the potencies fail.)
Other remedies which have proved useful in individual cases are Alumina, Cicuta, Ignatia, Nux v., Physos and Pulsat. Division of the affected nerve may be necessary in aggravated cases. The use of galvanism is often of great value in some cases-the positive pole is applied on any discoverable pressure point and the negative to the back of the neck. Canthomy, the division of the structures at the outer canthus by means of scissors, may be valuable in cases of tonic spasm.
Nictitatio-Constant blinking is frequently met with, especially in children and nervous, delicate persons. It is also sometimes present in exhaustion from excessive drinking, etc. This condition is generally due to some irritation in the eye itself, or may be reflex, from worms, decayed teeth, etc. Remove the cause, if determinable, and Agaricus will complete the cure.
Blepharophimosis-Narrowing of the palpebral opening from contraction of the skin of the lid is usually caused by chronic conjunctivitis, especially when flabbiness of the skin in old age favors such a formation and is relieved by canthotomy.
Symblepharon-Adhesion, partial or complete, of the eyelid to the eyeball. This condition occurs when, as the result of destruction of the mucous membrane from burns, as acids or lime, etc., or after diphtheritic or trachomatous conjunctivitis, two opposed portions of the conjunctiva grow together and may be either partial, when but one or more bands extend between the lid and globe, or complete, when the entire surface of the lid is attached, to the globe. The lower lid is most commonly adherent, and more or less limitations in the movements of the eye ensues. It may comprise the cul-de-sacs or the border of the lids (Fig- 33). The thickness of the adherent portions may vary, and we will have a sarcomatous, membranous or fibrinous symblepharon. Owing to the restrictions in the movement of the eye,and from the possible loss of vision due to its covering the pupil, every means must be tried to prevent adhesions in burns of the conjunctiva. To accomplish this the wounded surfaces must be separated daily during healing by some mechanical means, and the application of oil or vaseline to prevent their sticking together. The mucous membrane in these cases is destroyed to such an extent that simply dividing the adhesions will do no good, as they will at once grow together again. There are two methods of operating upon these cases with some prospect of success. First by separating the affected portions and inserting conjunctival flaps brought from neat by or from the opposite side of the cornea between them, or second, failing in this, to transplant from another person.
Ankyloblepharon is an adhesion of the ciliary margins of the eyelids. It may be complete or partial, often combined with symblepharon, and is acquired from burns or wounds, or congenital. The treatment is by inserting a grooved director behind the lids and dividing the adhesions, or, when extensive, by canthoplasty with sutures in the conjunctiva to present re-adhesion.
Lagophthalmos, is an incomplete closure of the palpebral fissure when the lids are shut together, and in the most cases there is inability to close the eyelids. It may result from a paralysis of the orbicularis, cicatrices in the skin of the lids, exophthalmos, staphyloma, etc. The danger of this condition is from ulceration of the cornea, due to its exposure to air and external irritants, owing to the inability to remove foreign substances by winking.
TREATMENT-In paralytic cases galvanism, with remedies directed to the cause of the paralysis ( such as syphilis, rheumatism, etc.) will often result in a cure. Cases that do not yield to this treatment require the operation of tarsorrhaphy to reduce the size of the opening of the eyelids.
Epicanthus is a congenital deformity in which a crescentic fold of skin projects in front of the inner canthus. It may also be seen in persons with flat noses, such as Mongolians, or syphilitics. As the child grows it disappears altogether, or becomes much less noticeable, so that operative interference is only called for in high degrees for cosmetic purposes. The operation is to remove an elliptical piece of skin from the bridge of the nose and uniting the edges of the wound together with sutures, care being taken to secure union by first intention by preventing any dragging on the stitches.
Trichiasis and Distichiasis- Where there is an irregularity in the shape and position of the eye-lashes so that they become curved in and in contact with the eye, it is called trichiasis, and where there is a double row of lashes, one of which is in contact with the eye, it is called distichiasis. Inverted cilia may affect part or the whole of the lid, and are usually thin pale or stunted. They cause more or less irritation of the eye, sometimes ulcers, pannus, etc., and are usually due to blepharitis, trachoma, injuries, burns, etc.
TREATMENT-Where there are but a few ingrowing lashes, epilation, if often repeated, may cause an atrophy of the hair bulbs and in this way cure the case (Fig.34 ). Electrolysis, as a curative measure, is most serviceable when the lashes to be destroyed are not too numerous. This is done by inserting a needle into the hair follicle and then connecting it with the negative pole of the battery, the positive being applied to the temple.
Arlt's operation, when modified to meet the emergencies of the case, seems to be the most generally advisable method of operating for the severe cases and is shown in the illustration (Fig.35). An incision two or three mm. in depth is made along the free border of the lid, splitting it into two layers.
A narrow strip of skin is then excised from the lid, cutting down to the first incision, as shown in the dotted lines in Fig. 35, so that the cilia remain in a bridge of tissue, which is shifted upward and its upper edge attached by sutures to the skin of the lid-its lower margin being left free. To avoid cicatricial contraction drawing the cilia down again, some transplant a narrow strip of the skin removed from the lid into the space that the gapes open in the free border of the lid.
Entropium is an inversion of the eyelid. We find two varieties of entropium; first the spastic, which is usually of the lower lid and is due to a spasmodic contraction of the orbicularis muscle. It is often met with in old people, sometimes coming on after operations, and is due to the lax condition of the skin. It may also be due to irritation from a foreign body, from keratitis, etc. The second variety of entropium is the cicatricial, which gradually comes on during the process of cicatrization and is the result of granular and diphtheritic conjunctivitis, burns, etc., where there has been loss of substance in the conjunctiva. Entropium results in much irritation and pain in the eye. From the continuous scratching of the cornea from the inverted lashes, ulcers and pannus finally ensue.
TREATMENT- In the spasmodic entropium a cure may often be effected by painting the parts with collodion, which should be renewed every two or three days, or oftener, in order to keep the lid in position. Adhesive strips may be applied for the same purpose. If these measures do not suffice, and always in the cicatricial entropium, operative interference must be resorted to before a cure can be made. Owing to the excessive vascularity of the lids, free haemorrhage occurs from any operation upon the lids unless controlled by the use of entropium forces (Fig. 36). There are various operations for the relief of entropium, of which perhaps Green's is the most serviceable in the majority of cases. This is made by everting the lid and making an incision from the conjunctival side, parallel to and about two mm. above its free border through the entire thickness of the tarsus, the incision to extend from one canthus to the other. A strip of skin about two mm. above the cilia is then removed.
Three sutures are then passed from the conjunctival side of the cilia through the free edge of the tarsus to just above the lower border of the skin wound; from there they pass through the muscular fibres on the outer surface of the tarsus and emerge from the skin about half an inch above the upper border of the wound. On lying these sutures the ciliary border is everted and the skin wound closed. Streatfeild's operation is the removal of a strip of skin with subjacent muscular fibres and a portion of the tarsus, just above the border of the lid, by cutting a deep V-shaped groove in its outer surface.
Other operations are Arlt's, already described, and those of Hotz, Snellen, Pope and others.
Remedies may possibly be useful, if the inversion is recent and only slight in degree. The following are suggested: Aconite, Argent. nit, Calc. and Natrum mur.
Ectropium is an eversion of the eyelids. The eversion may be slight or so great as to expose almost the whole of the palpebral conjunctiva. Ectropium is also divided into two classes, the spastic, due to chronic inflammation and swelling of the conjunctiva, which separates the lid margin from the eye, and this separation serves to increase the trouble by causing the tears to flow over the lid, which , in its turn by this irritation, aggravates the existing trouble. This form is also sometimes seen in children due to the swelling and inflammation of the conjunctiva, with contraction of the orbicularis. There is also in some cases a drooping of the lower lid from paralysis of the orbicularis, or from a defective innervation of this muscle in old people, which allows the tears to flow over the lid and cause ectropium. The cicatricial ectropium is due to a contraction after loss of the skin of the lids or of the face, following burns, wounds, abscesses, caries of the edge of the orbit with adhesions of the skin, etc. TREATMENT-In cases of spastic ectropium we may sometimes give relief by replacing the lid and retaining it there for several days by the use of the compress bandage. Scarification or removal of a strip of the conjunctiva to reduce the obstruction from thickening of the conjunctiva, together with the slitting up of the canaliculus, to permit the passage of the tears through the normal channels, may be tried. Other operations recommended to correct this affection are legion, and, as they must necessarily vary in nearly every case, according to the cause, degree and position of the eversion, but two will be detailed.
No plastic operations should be attempted until all tendency to contraction of the cicatrices has disappeared. In all flap operations allowance must be made for shrinking.
In Wharton Jones's operation a V-shaped (Fig.37) incision is made to include all the cicatricial tissue possible; the flap thus formed is to be dissected from the underlying tissues, and the skin at either side undermined sufficiently to allow of the lid being returned to its normal position. The exposed surface is then to be covered by bringing together the edges of the V- shaped wound with sutures so that it becomes Y-shaped(Fig.38)
Dieffenbach's operations is especially useful in the cicatricial form of ectropium and is made by dissecting away the diseased tissue by triangular incision. A flap of skin is then loosened by careful dissection from the immediate neighborhood and shifted up on the exposed surface, where it is kept in position by pins and sutures (See Figs. 39 and 40) The surface from which the flap was removed, if small, will become covered by growth of the integument from the edges of the wound; but, when large, it should be filled with grafts of skin from other parts of the body. The ectropium may also be corrected by skin grafting from other parts.
Apis-Is especially indicated in the first stage of this affection, in which the swelling of the conjunctiva is very great.
Argent nit-If the lids are swollen, inflamed, everted and the puncta lachrymalis very red and prominent. The discharge of tears and pus is profuse.
Hamamelis vir.-A dilute solution of "Pond's Extract" applied locally is said to have cured a case occurring during the course of a severe conjunctivitis.
Little reliance must be placed upon internal medication in either entropium or ectropium, as operative measures are almost invariably necessary, except occasionally in the first stage.
Molluscum Contagiosum is an affection of the sebaceous glands. It consists of small, round, umbilicated whitish prominences which may become inflamed and go on to suppuration. It is a hypertrophy of the gland and the tumor is composed of epithelial elements. The contents can often be pressed out through the depression at the summit of the tumor. For treatment see chalazion.
Xanthelasma is a hypertrophy of the sebaceous glands and a fatty degeneration of the connective tissue of the skin. They appear as yellowish patches, especially on the upper lid. lvins The Hahnemannian Monthly, December, 1897. reports a case cured in fifteen treatments by the galvanic current of five milliamperes applied for fifteen minutes at each sitting., He used a special pliable silver electrode, two rods, 3/32 of an inch in diameter, so adjusted as to be easily approached to contact or separated to two inches. These two electrode points, wet in salt water, were so separated as to bring one at each end of the patch, on the normal skin. They may be removed when small by excision, for cosmetic purposes. Excision of large patches in some cases might result in ectropium.
Milium are small, circular, white tumors. They are removed by incision and pressing out of the contents.
Papillomata (warts) are occasionally found upon the edge of the eyelid and upon the conjunctiva. They should be snipped off.
Dermoid cyst is congenital, and contains hair-follicles, hairs, connective tissue, fat, etc. It is generally situated at the outer angle of the orbit, develops slowly and causes but little inconvenience. It should be removed without rupturing the tumor, if possible.
Naevi are found on the eyelids and are similar in appearance to those occurring elsewhere. They are best removed by the galvano-puncture.
Chalazion (Meibomian or Tarsal Cyst)- Latest authorities seem to consider a chalazion as a granuloma in connection with a Meibomian gland, and not a mere retention cyst. There is, however, at the same time associated with it an inflammation of the larger than a good-sized pea; several may occur at the same time or they may recur in successive crops. It is hard and tense to the touch, and the skin is freely movable over it, but the tumor is adherent to the underlying tissues (Fig.41)
It develops slowly, causing to inconvenience for months. It may suppurate, and, when it does, it usually points on the conjunctiva.
TREATMENT-Excision, as a rule, is the most satisfactory treatment of tarsal tumors, providing there are only one or two. But as it is usually tedious and painful to remove entire a small solid tumor, we may substitute for excision, opening of the tumor, squeezing out its contents, and stirring up the sac with the point of a knife. The opening of a chalazion should always be through the conjunctiva if possible. It may have to he repeated several times, but as there will be little pain attending the operation, no objection will be made by the patient. After opening, I usually give Hepar low to promote absorption of the sac. In the case of cystic tumors the whole of the cyst wall should be removed; it may be destroyed by the use of seton, but removal with the knife is usually more satisfactory. Many cases have been cured by internal medication alone, and remedies should always be employed, whether the knife is used or not, for they no doubt hasten the cure and serve to prevent recurrence. Staphisagria-An important remedy for tumors of the lid. It is my custom to apply the tincture externally at the same time the remedy is being taken in potency. Enlargement of the glands of the lids, which are red and accompanied by tensive tearing pains, especially in the evening. For little induration of the lids, resulting from styles, or for successive crops of small tarsal tumors, this drug is especially indicated.
Thuja-This is one of the most valuable remedies for tarsal tumors, whether single or multiple, especially if they appear like a condyloma, either of the internal or external surface of the lid. We have seen them disappear by simply giving the drug internally, though it usually seems to act more speedily if we use, at the same time, the tincture externally. It is also recommended for the prevention of their return after removal by the knife. For condylomata, or warty excrescences on the lids, especially if occurring in syphilitic subjects, this drug deserves attention.
Hepar-Tarsal tumors that have become inflamed and are sensitive to touch. It also aids absorption after operation.
Calcarea carb.- Tarsal tumors occurring in fat, flabby subjects.
Causticum-Tumors, especially warts, found on the lids and eyebrows.
Conium-Induration of the lids remaining after inflammation. Pulsatilla-Tarsal tumors of recent origin that are subject to inflammation, or are accompanied by catarrhal conditions of the eye. The temperament and general symptoms will decide the case.
Zincum-Tumors of the lids with soreness and itching in the internal canthi.
Baryta car, and iod., Graph., Lyco., Kali iod., Merc.,Nitric acid, Sep., Sil. and Sulph. may be required.
Epithelioma is the most frequent malignant growth affecting the eyelid. It rarely occurs before the age of forty, and appears first as small hard nodules, and later becomes covered with a scab, which, on being removed, shows a slight excoriation; this increases to an ulceration of considerable depth, with purulent secretion and irregular, hardened edges. It may remain indolent for months, then assume an active stage, leading rapidly to extensive destruction of tissue. In the early stage there is little or no pain, but becomes excessively painful in the later stages.
Epithelioma, lupus and chancre have a very similar general appearance.
DIFFERENTIAL DIAGNOSIS.
Epithelioma.
Indurated irregular edges.Slow growth.Attacks middle-aged and elderly people.
Lymph glands of neck involved late. Lupus.
Less induration. More inflamed.Growth slower than epithelioma Lymph glands involved late. Generally associated with lupus elsewhere in body.
Chancre.
Indurated, but edges more rounded. Rapid growth. Usually in younger subjects. Lymph glands early involved.Other symptoms of syphilis.
Lupus and Sarcoma have both been found affecting the eyelids. A lupoid growth is more slow in development than an epithelioma, and both may result in ulceration; but as Noyes Diseases of the Eye, 1890. so well says, "A discrimination between them is hardly needful for practical purposes."
TREATMENT-Excision is advised in all malignant growths of the lids, if the disease is circumscribed and moderate in extent; care being taken that all the morbid tissue is removed. The edges of the wound may be brought together by sutures, or a plastic operation may be made, bringing the integument from the temple or some adjoining point.
Juler 2 Ophthalmic Science and Practice, 1884. advises scraping away all the diseased tissue by means of a small steel scoop. This is attended with considerable haemorrhage and is tedious, but he claims its success in arresting this malignant affection is marvellous.
Various caustics have been employed, chief among which may be mentioned caustic potash, nitrate of silver, chloride of zinc, arsenic paste and acetic acid. An objection to the use of caustics lies in the deformity apt to occur afterward. Electrolysis has been recommended.
If the disease is very extensive, involving the tissues of the face to such an extent that extirpation is impracticable, we then rely chiefly upon our internal remedies, using only such local applications as prove agreeable and of temporary relief to the patient. For instance, if the discharge is profuse and offensive, a weak solution of carbolic acid, salicylic acid, or some other disinfectant proves of service. An application from which we have often seen excellent results is carbolic acid and linseed oil (4 grains to the ounce): it relieves the patient and seems to exert a beneficial effect over the progress of the disease.
Iodoform-Dr.George A.Shepard reports surprising results in two cases of lupus from the administration of this drug in the third decimal trituration.
Apis-Lupus non-exedens, sharp, stinging pains, and tendency toward puffiness of the lower lids. Hydrocotyle asiatica-Has obtained a high reputation in the hands of Dr. Boileau as a remedy for lupus and deserves our attention.
Phytolacca dec-Benefit seems to have been derived in relieving, if not curing, malignant ulcers of the lids, when used both externally and internally.
Thuja-Epithelioma of the lids.
Syphilitic Ulcers, Chancre, and Gummata are all occasionally found on the eyelids, and should be treated the same as occurring elsewhere. The most useful remedies are the following prescribed according to general indications: Ars., Apis., Aurum Cannab, Hepar, Kali iod., Merc., Nitric ac., and Thuja.
Herpes Zoster Ophthalmicus commences with severe neuralgic pains along the supraorbital division of the fifth nerve of one side, sometimes the nasal and rarely the infra-orbital branch of the same nerve. The skin becomes swollen and red, covered with herpetic vesicles which unite, crusts form upon them, followed by ulcerations which ultimately leave deep cicatrices. The cause of the disease is probably an inflammation of the nerve and the Gasserian ganglion belonging to it. The disease involves one-half of the face, never extending beyond the median line, and has often associated with it corneal ulcers and iritis. The intense pain that precedes the herpetic eruption may last for a few hours, or extend over months, but usually subsides with the appearance of the vesicles. TREATMENT-the remedies most useful are; Ars., Croton tig., Electricity, Canth., Graph. Merc, Puls, Ranunc., bulb and Rhus.
Contusions are very often found, and are frequently accompanied by some lesion of the globe on orbit.
TREATMENT-Immediately after contused wounds of the lids, cold compresses should be employed; they should be applied with a firm bandage, which often proves of advantage in limiting the amount of ecchymosis.
Arnica, our great remedy for all contusions, deserves its extensive reputation for curing "black eyes," as there is no other drug better adapted to this condition. A solution of the tincture in water, ten drops to the ounce, is usually employed, though both stronger and weaker solutions are in vogue. Ledum, used in the same manner, has also proved of service.
Wounds- We may have an incised, lacerated, or penetrating wound of the lid; and, in all cases, the condition of the orbit and globe should be carefully examined to see if they remain intact.
TREATMENT-The first object in view should be to bring together the edges of the wound by means of sutures, adhesive strips or collodion. If the wound is incised, without any contusion, and the edges are early brought accurately together, a dry dressing will often be found most beneficial.
Hamamelis and Ledum have both been recommended for wounds of the lids.
Burns and Scalds must be treated as usual in other parts of the body, except that care should be taken to prevent the union of the lids (ankyloblepharon) by frequently opening them, and by inunction of the edges with simple-cerate or cosmoline; also, great attention should be paid to the prevention of a cicatrix (which causes ectropium) by keeping the skin on the stretch by a bandage during the period of cicatrization. Cosmoline is especially recommended as an external application.
When dependent upon the stings of insects, the sting should be removed and cold water dressings applied.
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