A peculiar case of herpes zoster ophthalmicus, serous iritis, or 'ophthalmo-neuritis' / by George M. Gould.

  • Gould, George Milbrey, 1848-1922.
Date:
1888
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Licence: Public Domain Mark

Credit: A peculiar case of herpes zoster ophthalmicus, serous iritis, or 'ophthalmo-neuritis' / by George M. Gould. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    that the primary or chief lesion was in the iris. In the early and most painful periods of the affection the iris was, if at all, only slightly hypersemic, and a pronounced or plastic iritis appeared only after the crisis of the disease had passed, and even then it was not severe or painful. Moreover, almost every writer in discussing that pecu- liar, rare and somewhat mysterious disease, serous iritis, admits, to start out with, that the inflammation is more extensive than the iris, that it is an irido-choroiditis, an uveitis, or even a true panophthalmitis. Thus Ulrich,* in discussing the nutrition of the eye, says, “ All are agreed that iritis serosa is not only an iritis. The case of Knies has of late furnished anatomical proof that the whole eye shared in the inflamma- tory process, so that instead of an iritis serosa it were more properly designated as a panophthalmitis serosa. * * * Only after the disease has progressed for a considerable time does a true iritis appear with synechiae, and only at a still later day begin the forma- tion of deposits upon the membrane of Des- cemet.” DeWecker, in exposing his theory thatserous iritis is primarily a lymphangitis of the anterior part of the globe, saysf that the term serous iritis must soon disappear ; and he adds, “ Probably every anterior lymphan- gitis that at first preferentially seizes upon the pericorneal trabecular tissue, is imme- diately extended to the ciliary body, and .should therefore be called a serous irido- choroiditis, or general lymphangitis of the eye.” But the famous case of Knies, the unique post-mortem proof of the actual condition of the tissues, shows most un- equivocally that the whole uveal tract and the optic nerve up to the chiasm were pro- foundly affected. It seems strange that Arlt’s division upon iritis from cold, or rheumatic iritis, has not been more fre- quently illustrated clinically, or that cold, * Grae/e, Archiv /Ur Ophthalmologie, 26-3-62. t Train Complet d’ Ophthalmologie, Toms ii, Fasc. 2, pp. 280 and 313. as an etiological factor, has not been accepted by other writers. My present contention, however, goes beyond this, and relates to the whole nomen- clature and the essential nature of the lesion. To designate the consensus of symptoms and lesions by the term iritis is not only im- perfect, but is wholly misleading and incor- rect. It would be extreme to say that all cases heretofore described as serous iritis were, properly speaking, examples of periph- eral neuritis; but it is less absurd than to designate the disease I have described as simply an iritis; and it may indeed finally transpire that many cases of so-called serous iritis are in reality neither entirely localized to the uveal tract, nor, as DeWecker argues, essentially of the nature of a lymphangitis, local or general, but are really examples of a more or less general neuritis of the ocular nerves. There seems hardly a reasonable doubt that my case was such an one, and that most of the structures dependent upon the ophthalmic branch of the fifth, as well as the optic nerve itself, were peculiarly affected, and in such a way that no other cause than neuritis could explain the symptoms. The vaso-motor connections of the ophthalmic branch explain the sudden, extensive and persistent flushing of the conjunctival and subconjunctival capillaries, either by direct interference with the neural transmission, or as a reflex neurosis. Perhaps the same ana- tomical and physiological connections may account for the lachrymation and photo- phobia. The exquisite and ceaseless pain is seen to be a necessary consequence. The iritis or uveitis thus appears as a late and a secondary result, due either to extension of the inflammation from the nerves to the proper tissues or to vaso-motor disturbances. The implication of the optic nerve, papilla and, perhaps, retina, may be explained in the same way. The duration of the disease, one to two months, is what we should expect from analogy with the neuritis of other peripheral nerves.