Archiv. Ophthal., June, 1888, p. 188. details numerous exhaustive experiments upon both dogs and rabbits, made with the expectancy of confirming Deutschmann’s results, but in no instance was sympathetic ophthalmia a sequel of the operation, and hence his results were entirely negative so far as confirming those obtained by Deutschmann. Galezowski Soc. d’Opht. de Paris, October 7, 1890. thinks the inflammation is carried from one eye to the other through the ciliary nerves and their lymph channels and not through the optic nerve. Further, the fact that sympathetic ophthalmia is most frequently apt to occur after wounds in the ciliary region, and also that it never, or very rarely, occurs in suppurative diseases of the eye, such as panophthalmitis, where the ciliary nerves are destroyed, leads us to think that the most frequent path of the transmission is through the ciliary nerves. PROGNOSIS.-In the pspecial indications see Part II.
Numerous affections of the eye are supposed to be due to a pre-existing inflammatory condition of the other eye and hence are called sympathetic. The most frequent form of sympathetic inflammation is that of irido-cyclitis, or irido-choroiditis. It is claimed by many writers that we may have a sympathetic iritis, keratitis, choroiditis, neuritis, retinitis, etc. Fuchs and some others, however, question if these disease are the result of sympathetic involvement. Glaucoma even has been considered by some as possibly occurring from sympathetic irritation, although this is now disputed by the best authorities. As the disease may assume so many varying forms and may result in pathological changes in nearly all the structures of the eye, a special study of its pathology is therefore too complex to be undertaken here. We will, consequently, content ourselves with simply referring to the pathological processes detailed under the study of the other disease and especially those of the uveal tract. This disease, in its more serious form, is of the greatest importance, for, if not cut short in its earlier stages, it almost inevitably leads to blindness.
The disease has what may be termed a prodromal stage, during which it is called sympathetic irritation. At this time the patient complains that the eye soon grows tired on using it. There is more or less sensitiveness to light, lachrymation and slight pericorneal redness. The most important symptoms at this period are, a failure in the vision and a diminution in the range of accommodation, owing to the affection commencing usually in the ciliary body. During this stage there is also apt to be found a more or less sensitive spot in the disease eye. These symptoms of slight irritation of the eye may exist for a long period, or possibly might never lead to the dreaded sympathetic inflammation, but as a rule there is a gradual increase of the pain and cloudiness of the aqueous with a decrease of the visual acuity, as the stage of sympathetic inflammation sets in. Sympathetic ophthalmia may also set in without any of the previous symptoms of sympathetic irritation.
SYMPTOMS.-There is a loss of vision, due to haziness of the vitreous, which in the early stages is diffuse, but later we find large opacities floating about. Photophobia, lachrymation and ciliary neuralgia are present in varying degrees in different cases. The ciliary region is very sensitive to touch. The range of accommodation, when it can be tested, is much diminished. There may be ciliary injection, or chemosis and the lids may be red and swollen. On examination of the eye we find the aqueous is hazy, due to the exudation into the aqueous from the ciliary processes, and this exudation may be deposited in masses on the endothelial layer of the cornea. The exudation extends into the iris and we have posterior synechiae, which form very rapidly, even resulting in complete exclusion within twenty-four hours, but may be more gradual. As the exudation goes on the iris becomes very much swollen, a false membrane forms attaching it to the lens throughout its entire extent, resulting in complete occlusion of the pupil. There is a venous engorgement of the iris, and its entire structure becomes degenerated. The anterior chamber becomes shallow, the opacities in the vitreous increase all the time, the choroid becomes affected and we have an inflammation of both the choroid and retina. The periphery of the iris is drawn back and its pupillary edge, together with the lens, is pushed forward. Vision at last becomes entirely lost. The tension is increased during the early stages, but later becomes diminished. The field of vision becomes contracted very early in the course of the disease.
The foregoing describes a marked or severe form of sympathetic inflammation, but we may have a more mild type of the disease, which assumes a serous rather than a plastic form of inflammation. In this there will be some pericorneal injection, the iris somewhat discolored, with a few slight adhesions and the sight slightly reduced. In some cases there may be a papillitis or neuro-retinitis, and in these light cases the eye may entirely recover. Other more rare conditions, such as conjunctivitis, keratitis, etc., have been reported as due to sympathetic irritation and have been relieved upon removal of the diseased or exciting eye.
CAUSES.-The most frequent causes of sympathetic inflammation are foreign bodies and injuries, especially when occurring in the ciliary region; operations at the corneo-scleral junction, as in cataract extractions, contraction of scars, or rupture of the sclera at the ciliary region, previous inflammations of the eye where the eye has become atrophied and especially when accompanied by chalky or bony formations within the eye, intra- ocular haemorrhages or contusions of the eye, prolapse of the iris and anterior synechiae, external irritation of an atrophied ball, as when an artificial eye is worn upon a shrunken stump, and in fact any eye that has been lost and is painful may awaken a dormant tendency to sympathetic inflammation.
The period during which there is a danger of transmission of sympathetic inflammation varies from two weeks to thirty years; the most frequent period, however, seems to be from four to eight weeks. There is, then, practically no period during which an injured or diseased eye may not be the cause of sympathetic irritation of its fellow. From the statistics of this disease by Gunn and others there seems to be no difference in the result or severity of the sympathetic, inflammation, whether there is a short or a long interval between the primary lesion and the onset of the sympathetic disease of the other eye. According to some there is a greater tendency to sympathetic ophthalmia in young individuals, while others hold that there is less. It is also claimed by some that it never occurs unless there is a perforating lesion of the exciting eye; or, at any rate, that it is extremely rare.
As to the method of transmission of the sympathetic irritation very much has been written and many experiments made, still the exact mode is far from being definitely settled. The condition, it seems to us. from the experiments of the various investigators of this subject, may be transmitted either through the ciliary or the optic nerves, with the weight of the evidence in favor of the former.
Mackenzie in 1840 and followed later by Alt, Leber and Deutschmann, by means of experiments and microscopic examinations, have argued in favor of the optic nerve being the path along which the affection extends. Deutschmann v. Graefe’s Archiv. fur Ophthalmologie, xxviii., 2; xxix., 4; xxx., 4. made experiments upon rabbits, first by injections of spores of the aspergillus fumigatus into the vitreous, with the result of causing choroido-iritis in the injected eye, and four weeks later the same condition, together with opacities in the vitreous, was found in the other eye. Microscopic examination revealed an interstitial neuritis extending up to the chiasm and down to the other eye by way of the optic nerve. Later he resorted to the pus organisms for the inoculating material and made injections of a suspension of staphylococcus pyogenes aureus. Subsequent microscopic examination reveals purulent infiltration of the optic nerve, with diminishing intensity up to the chiasm, and then with increasing intensity down to the other eye. He, therefore, concludes that sympathetic ophthalmia is propagated through the optic nerve. A few years later Deutschmann On Ophthalmia Migratoria (sympathetic ophthalmia) Hamburg and Leipzig, 1889. published his views in a very complete paper and claims that the disease is a process of microphytic origin, passing from one eye to the other through the optic nerve apparatus and suggests that the name ophthalmia migratoria better expresses the character of the disease than does sympathetic ophthalmia. He also claims that it should be kept separate from an affection of the other eye dependent upon an irritation of the ciliary nerves of the first eye, and which should be called reflex irritation. In opposition to these theories of optic nerve transmission we find H. Muller Plus Archiv. Ophthal. (Graefe), vol. iv., I, 1858. pronouncing in favor of the ciliary nerves. Randolph (++) Archiv. Ophthal., June, 1888, p. 188. details numerous exhaustive experiments upon both dogs and rabbits, made with the expectancy of confirming Deutschmann’s results, but in no instance was sympathetic ophthalmia a sequel of the operation, and hence his results were entirely negative so far as confirming those obtained by Deutschmann. Galezowski Soc. d’Opht. de Paris, October 7, 1890. thinks the inflammation is carried from one eye to the other through the ciliary nerves and their lymph channels and not through the optic nerve. Further, the fact that sympathetic ophthalmia is most frequently apt to occur after wounds in the ciliary region, and also that it never, or very rarely, occurs in suppurative diseases of the eye, such as panophthalmitis, where the ciliary nerves are destroyed, leads us to think that the most frequent path of the transmission is through the ciliary nerves.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.