Iritis

“ The chief sources of iritis are syphilis, gonorrhœa, tubercle and infections from undifferentiated organisms of low grade. If these said iritides occur in a person of gouty diathesis they are unmodified by it clinically or pathologically, macroscopically or microscopically, save possibly in the direction of chronicity—a result, it may be, of those inherent peculiarities of tissue metabolism ingrained in a gouty subject, and in which presumably the iris shares. ”

“ A man has iritis and tophi; ergo we say he has gouty iritis. But why? They co-exist, it is true, but where is the link of attachment of cause and effect? How different is our attitude if we know in another case that our tophaceous iritic patient has gonorrhœa. We then say, gonorrhœal iritis in a gouty subject. Would it not also in the first case be more scientific if we frankly confessed that it was an infective iritis of undifferentiated type occurring in a person of gouty diathesis?
In considering the iritides in relation to gout there are two types which demand our attention. ”

“ The same condition has become familiar in connection with experimental inoculation in the eye. As in ordinary iritis adhesion to the capsule of the lens and cataract are common results.
Apart from the treatment of the specific primary disease this type of iritis demands the same treatment as other forms. Strong atropia lotions to prevent or break up adhesions and antiseptic astringents are especially indicated. When implication of the second eye is threatened it may be desirable to remove the first by enucleation. (See Panophthalmitis) . ”

“ Some cases become chronic and last much longer. Others are chronic from the first, and in one clinical type of iritis, in which the ciliary body is also at the same time affected, viz. iritis serosa, there is usually comparatively little injection of the eye or pain, so that the patient’s attention may only be directed to the eye owing to the gradual impairment of sight which results. ”

“ Before the dogma can be accepted that because a gouty man has iritis it is therefore a gouty iritis and, like the poet’s primrose, nothing more, it must be shown that irido-cyclitis is proportionately more frequent in people who are gouty than in those who are not. Even then it is suggestive, but not conclusive, for it is conceivable that, although gout is not strictly the cause, yet it may so reduce the resisting power of the iris that it becomes a readier prey to some lurking organism. ”

“ If, however, we adopt the infective theory, then the association of the uratic deposits no longer dominates our creed—we view them as mere clinkers and by-products erupted from the furnace.
The infective theory of gout also lends plausibility to an association with iritis, for this latter is a disease of infective origin. For the intimate relationship of all forms of asthenic arthritis with iritis is of very frequent occurrence, but is practically never seen in the more sthenic arthritides: rheumatic fever, acute gout and traumatic arthritis. ”

“ In rheumatic iritis he states that the patients “are often gouty.” The gouty nature of iritis is indicated by the similarity of onset of some cases of iritis with that of gout. “Iritis in an elderly patient is likely to be gouty, often starting suddenly in the night and sometimes ushering in an attack of gouty arthritis.” In episcleritis “rheumatism and gout are commonly indicated as the chief causes.”
Werner [45] includes gout in a list of disorders of metabolism which produce iritis “by means of toxins of a chemical nature.” ”

“ If a case of iritis be left to itself or treated without the use of a mydriatic, posterior synechiae almost invariably form. Some fibrinous exudation may even organize into a membrane stretching across, and more or less completely occluding, the pupil. Synechiae, though not of themselves causing impairment of vision, increase the risk that the eye runs from subsequent attacks of iritis. ”

“ Chronic irido-cyclitis is usually primary, but may occasionally follow an acute attack of iritis. Of all the disastrous complications, this is by far the worst. It may not only destroy the sight of the eye on which the operation has been performed, but may set up sympathetic ophthalmia in the other eye. The eye does not settle down well after the operation, there being usually some prolapse of the iris or capsule into the wound. ”

“ Gout is a rarer disease than our patients would have us believe, but accepting their views, even then we should expect to see more cases of iritis caused by it, if such existed; we should expect to find more definite proof of a causal connection, and less frequently a history of gonorrhœa, of pyorrhœa, and of syphilis. ”

“ A gouty man is gouty to his innermost cells, and the eye, like every other part of the body, is a potential uratic site. We must grant therefore that the course of an iritis, however caused, may be influenced, though not necessarily dominated, by the diathesis. Consequently it may be necessary that cases of iritis of undoubted gonococcal or other infective source occurring in gouty people should be treated by iodides, salicylates, atophan or colchicum. ”

“ If then a gouty man is not immune from other possible causes of iritis, one of these, and not gout, may be responsible for it. Especially is a gouty diagnosis doubtful when there is a focus of suppuration in the tonsils, teeth or elsewhere. Also the prolonged hibernation of the gonococcus, for many years after the attack [318] of gonorrhœa, is apt to be overlooked. The presence of excess of uric acid in the blood, which sometimes occurs in these patients, may mislead us into the belief that we have a true gouty iritis to deal with. ”

“ The realm of medicine, with ever widening borders, is too vast for single control. In the foregoing pages I have said much about iritis, and it is a good example of what I mean. In justice to our patient, we may call for a Wassermann or a complement fixation test; we may require the teeth-roots made visible by an X-ray expert, or, it may be, the passage of a bismuth meal radiographed, hidden tonsils explored by the laryngologist, or the antrum illuminated; the fæces may need bacteriological examination. ”

“ The patient complains of impairment of sight and of frontal or supraorbital pain. The eye waters and is hypersensitive, the iris is discoloured and reacts sluggishly to light, and there is a zone of ciliary congestion around the cornea. The appearance of minute white nodules or flakes of lymph at the margin of the pupil is especially characteristic of syphilitic iritis. ”

“ That recurrent attacks of iritis are frequent in some individuals who have recurrent attacks of chronic inflammation of the joints is a fact familiar to many practitioners, amply attested by the cases published by Hutchinson293 and by Foerster.294 As regards gout, the direct proofs of its relations to eye disease are still less manifest, and most cases supposed to be attributed to this cause by both the older and more modern writers are to be classed as primary or secondary glaucoma. ”

“ According to the nature and severity of the exudation there may be deposits formed on the back of the cornea, attachments between the iris and lens capsule (synechiae) , or even gelatinous-looking coagulations or pus in the anterior chamber.
The subjective symptoms to which the inflammation may give rise are dread of light (photophobia) , pain, generally most severe at night and often very great, also more or less impairment of sight. Along with the pain and photophobia there is lacrymation. An acute attack of iritis usually lasts about six weeks. ”

“ In the Joints, a serous synovitis or hydrops may occur, chiefly in the knee, on one or on both sides.
The Affections of the Eyes, although fortunately rare, are of great importance because of the serious results which may follow if they are not recognised and treated. Iritis is the commonest of these, and may occur in one or in both eyes, one after the other, from three to eight months after infection. The patient complains of impairment of sight and of frontal or supraorbital pain. ”

“ Gout does not render patients immune from tuberculous, syphilitic or gonococcal disease, and when in such so-called diathetic stocks an iritis occurs, especially in gonorrhœa, years after the primary disease, it is probable that gout, rather than lues, will be assigned as the cause. ”

“ In infected cases a complication with iritis is not uncommon owing to the penetration of toxines into the anterior chamber.
Inflammations of the cornea are the most important diseases of the eye, because they are among the most frequent, because of the value of the cornea to vision and because much good can often be done by judicious treatment and much harm result from wrong interference and neglect. The treatment of primary keratitis must vary according to the cause. ”

“ The formation of gummata in the iris, which are generally seen in the smaller circle, is much rarer, generally developing in the tertiary stage of the disease; occasionally they are developed in the ciliary body. In the former situation they usually disappear under active treatment, leaving fair vision in the eye, but when situated in the latter place they usually lead to shrinking and atrophy of the eyeball, even under the most vigorous treatment. When iritis occurs in infants it is generally specific in origin. ”

“ The irritation produced sets up inflammation of Descemet’s membrane and the cornea, together with iritis, and, secondly, keratitis and changes in the lens.
Unless treatment is adopted verminous ophthalmia inevitably ends in cataract.
Diagnosis. Diagnosis is always uncertain on account of the difficulty of examination. When the cornea is very opaque examination necessarily gives a negative result.
The prognosis is grave. ”

“ Alterative does of calomel and antimonials, when the eruption declines.
The local treatment consists in astringent washes and simple dressings.
Iritis is to be cured by venesection, cathartics, mercury, blisters, and belladonna.
This disease will yield to the powers of the constitution. Mercury is always injurious in the early stage.
Second, Pustular venereal disease.
Primary ulcer of a reddish-brown colour; borders closely on the phagedenic character. The edges raised and well defined; not excavated, but on a level with or above the surrounding skin. In the commencement, a small itchy pustula ”

“ In other words, it may yet happen that the mysterious materies morbi of gout, whether microbic or chemical, may be demonstrated experimentally as capable of inducing, not only the arthritic phenomena, but also those inflammatory lesions in the eyes which provisionally are sometimes called “gouty.”
Lastly, I would enter a plea for more systematic, more scientific, investigation of the true link, if any, between iritis and arthritis. The war has taught us the value of “team-work”; it has taught us that the clinician must be reinforced by the bio-chemist, the bacteriologist and the pathologist. ”

“ These figures would indicate that the coucher was losing 60 per cent. more eyes than the hospital did even then. If the vast number of eyes submitted to couching be taken into account, this 60 per cent. of avoidable loss totals up to a staggering figure. Nor must we disregard the fact that, even amongst the successes, the average vision obtained is greatly in favour of the Western surgeon.
The table showing the causes of failure will repay a careful study. The figure for iritis and iridocyclitis comes to 35·76 per cent. ”

“ Its primary symptoms are, a simple ulcer without induration, without elevated edges, and without phagedena. Sometimes there is a patchy excoriation of the glans penis, attended with a purulent discharge. This disease and gonorrhœa are caused by the same poison. The constitutional symptoms are:—fever; pain in the head, shoulders, and larger joints, pain in the chest; dyspnœa; a papular eruption on the forehead, chest, and back, sometimes extending in a more scattered way over the extremities. It is often attended with iritis. It never gives rise to nodes. ”

“ Perforating wounds are accompanied by injury to the lens and other structures; when the cornea is wounded it is often complicated by falling of the lens. When a small foreign body passes through the cornea and iris a small opening may be seen. The greatest danger from wounds is due to infection and if it reaches the iris, it may produce violent iritis. If the lens is displaced or absent the iris being without support, will tremble with every movement of the eye. ”

“ Treatment is unsatisfactory. Preventive measures consist in avoiding conditions favorable to the production of the disease. This should be practised so far as possible. At the time the attack occurs, the animal should be given a cathartic. One pound of Glauber's salts in a drench is to be preferred. Rest in a darkened stall is indicated. An eye lotion containing three grains of silver nitrate in one ounce of distilled water should be applied to the eye three times daily. A water solution of atropine or eserine should be used for the purpose of relieving the symptoms of iritis or glaucoma. ”

“ The patient may be either wholly free from symptoms and in good health, or he may remain pale and rather feeble, and liable from time to time to slight returns of eruption on the skin, sores on the mucous membranes, condylomata, etc. He is protected as regards fresh contagion, and should he beget children they are almost certain to suffer. The relapses during this stage are usually easy to be distinguished from true secondary symptoms. There is little or no febrile disturbance, the rash is not copious, and often not symmetrical. Acute iritis, retinitis, etc. ”