KERATITIS VESICULOSA WITH SECONDARY GLAU- 
COMA. 
THOMAS R. POO LEY, M.D., of New York, 
Assistant Surgeon N. Y. Ophthalmic and Aural Institute ; Ophthalmic Surgeon to Charity Hospital. 
Reprinted from the Archives of Ophthalmology and Otology, Vol. IV. No. i. 
THIS form of keratitis has already been sufficiently well de- 
scribed by v. Graefe, Horner, and Schmidt, but the case which 1 
am about to report has additional interest on account of the very 
unusual complication which followed. At the time when I saw 
it, I was not aware that any similar one had been published. I 
have, however, found two such observations recorded in litera- 
ture. Inasmuch as these, so far as I know, are the only ones, I 
believe it will not be without interest to place them together with 
mine. The first case on record is by VON Graefe.* He says 
that limited corneal infiltration (genuine circumscribed keratitis) 
has hardly any influence on the tension, as estimated by the touch, 
and this may explain why it is rarely, if at all, the cause of glau- 
coma. He had only once seen glaucoma following circumscribed 
keratitis, and briefly reports the case on account of its rarity. 
A woman, 50 years of age, who had suffered for many years from erup- 
tions on the extremities, and occasionally on her left cheek, applied at the 
■clinic, in June, 1866, for an ophthalmia of about one week’s duration. 
We found an old eczema behind the left ear, and an eczematous patch 
about the size of a four-groschen piece at the lower part of the left cheek, 
on both sides blepharadenitis, and finally the special cause of her applica- 
tion, a circumscribed infiltration of the left cornea. The latter presented 
typical characters. There was an opaque and somewhat swollen spot, 
measuring 1.5 mm., opposite the lower edge of the pupil; its centre was 
yellow and opaque, passed into a light gray towards the margin, and 
merged gradually into the healthy cornea; the centre also projected and 
presented a slight excoriation. The pupil was small; it dilated slowly on 
the use of atropine, owing to the existing irritation ; the vision was quite 
* Contributions to the Pathology and Treatment of Glaucoma, Archiv f. Ophth., 
xv., p. 108, and translation by Thos. Windsor, Koval London Ophth. Hosp. Reports, 
■vol. vii., p. 65. 47 
Thomas R. Pooley : 
‘in proportion ; the tension was not tested at first, as there seemed no 
reason for suspicion. The disease was unusually obstinate, which was 
attributed to the eczematous diathesis. This led to a more careful ex- 
amination, and it was expressly determined in the fourth, and again in 
the sixth week, that there was no complication with disease of the internal 
structures ; the tension was perfectly normal, not only within the physio- 
logical limits, it did not even reach the normal maximum, nor vary from 
that of the right eye. From this time, while the corneal disease remained 
perfectly stationary, there supervened a perfectly typical attack of sub- 
acute glaucoma. Paracentesis twice repeated had no permanent effect, 
and in the twelfth week from the commencement of the attack indistinct- 
ness of eccentrical vision on the nasal side necessitated iridectomy. 
The operation was followed by the desired reduction of tension, and 
rapid disappearance of the obstinate corneal infiltration. 
Graefe concludes that, as this is the only case in which he has 
noticed typical circumscribed corneal infiltration followed by 
glaucoma, it may well be imagined that the succession was acci- 
dental, or that both affections were due to the eczematous diathe- 
sis. 
The second case was reported by Saemisch at a meeting of the 
Medical Section of the Society of the Lower Rhine, held in Bonn, 
March 21st, 1870.* He presented a patient who had suffered for 
five months from keratitis \Vesiculosa, and remarked that the case 
merited attention because it deviated from those put on record 
in two respects ; First. Preceding the formation of the vesicle, 
there was an opacity of the cornea a few mm. long, arranged in 
long parallel or decussating stripes, formed in various layers of the 
cornea, similar to those described by Heyman, who supposes them 
to be opaque, or widened lymphatic corneal vessels. Second. 
When the disease was at its height, acute glaucoma supervened,, 
for which iridectomy was performed with good result. Saemisch’s- 
conclusion is just the opposite to that of v. Graefe. He thinks 
that in this case we are entitled to suppose that glaucoma was not 
a casual complication, but that it was secondary to and induced 
by the corneal process. 
I now come to my own case, which is as follows : 
In August, 1873, a Jewess, of about 40 years of age, came to the Oph- 
* Berliner Klinische Wochenschrift, No. 37, p. 449. IS7O. Keratitis Vesiculosa. 
48 
thalrnic and Aural Institute. Her left eye had begun to trouble her only 
a day or two before. She complained of lachrymation, photophobia, and 
supra-orbital neuralgia. There was considerable circum-corneal injec- 
tion. On oblique illumination a small, perfectly transparent vesicle of 
the cornea, about 1'" in diameter, below and a little to the outer side of 
the middle of the pupil, was to be seen. It was surrounded by a circlet 
of infiltration which gradually shaded off into the healthy cornea. The 
central vesicle was quite prominent, and at first I thought that 1 had to 
deal with an ulcer, with hernia of Descemet’s membrane. Upon more 
careful examination, however, this was determined not to be the case, 
and the diagnosis of Keratitis vesiculosa, or true herpes of the cornea, was 
made. The pupil was of normal size, responded well to light, and dilated 
under atropine. 
The anterior chamber of normal depth ; T.n. ; F. complete; S. = 
Ophthalmoscopic examination discovered no abnormality of the fundus. 
The treatment employed was instillations of atropine, warm applica- 
tions, and pressure bandage. Two days later I saw the patient again at 
her house. There was no material change in the appearance of the eye, 
but the pain was more severe. Leeches to the temple were ordered, and 
the other treatment continued. I saw the patient only twice after this, at 
intervals of a few days, and each time I examined the interior of the eye 
with the opthalmoscope, as well as the tension, visual field and sight, and 
never found any indication of glaucoma. I then declined further attend- 
ance on account of the patient’s obstinacy, but told her husband to take 
her to the clinic. This he did not' do. I was, however, surprised to 
hear from Dr. Knapp that on Get. 6th she presented herself at his office 
with absolute glaucoma. She was admitted to the Ophthalmic Institute,, 
where I saw her again. The pupil was wide and immovable; anterior 
chamber very shallow ; T. -f 3 ; no perception of light, and illumination 
with the ophthalmoscope was impossible. The eye was still very painful. 
She had continued the use of atropine since I left her, but further than 
this had done nothing, although she had suffered severe pain all the while 
and sight was gradually abolished. A small opacity of the cornea marked the 
site of the vesicle. Dr. Knapp made a large peripheral iridectomy, merely 
with the view of relieving pain. The operation had the desired effect in 
reducing tension and relieving pain, but no influence upon vision. 
The other eye was in all respects normal. 
These three observations are certainly sufficient proof to warrant 
thein ference that there may have been a causal rather than a cas- 
ual relation between the corneal and glaucomatous processes. 49 
Keratitis Vesiculosa. 
I am quite of the opinion that, in my case, the same conclusion 
must be arrived at as Saemisch came to in his, that is, that the 
glaucoma was the direct result of the corneal process. It is to be 
regretted that the opportunity of observing the course of the dis- 
ease was wanting, and it cannot, therefore, be stated just when 
the glaucomatous process began. 
In v. Graefe’s case the symptoms of glaucoma set in about 
the twelfth week from the commencement of the attack, and in 
Saemisch’s, when the disease of the cornea was at its acme, glau- 
coma supervened. It is difficult to state, in my case, whether 
the onset of the glaucoma was acute or not. I incline to the 
opinion, however, that it was sub-acute, as in v. Graefe’s case. 
As to the role which this form of keratitis may play in the 
aetiology of glaucoma, I have no theory of my own to offer, but I 
should like to call attention to the remarks made by Max Schultze 
(1. c.) in the discussion which followed the presentation of Sae- 
misch’s case. 
He said that he had recently read a paper by SCHWEIGGER- 
Seidel, of Leipzig, on the interstitial cavities (Spaltraume) of 
the cornea, and it seemed to him quite possible that the vesicles 
in question might be due to widening of these normal canals, 
which, according to the investigations of S.-S., show a great sim- 
ilarity to lymph capillaries. If the interstitial cavities of the cor- 
nea really communicate with lymph-vessels, the vesicles would 
have to be considered as ectasiae of lymphatics. Schultze also 
referred to a paper by Gustave SCHWALBE, on the lymphatic 
cavities of the eye, published in his Archiv f. Mikroskopische 
Anatomic, which contains a great many interesting observa- 
tions concerning the communication of the anterior chamber, 
canalis Petiti, and the ciliary veins with lymph-vessels. These 
observations are apt to throw a new light upon the conditions 
which give rise to intra-ocular tension. In applying these ob- 
servations to Saemisch’s case, Schultze remarks that the fact of the 
vesicle of the cornea existing before the outbreak of the glaucoma, 
enhances the probability that the increase of intra-ocular tension 
might have been due to an impediment to the out-flow of lymph 
(perhaps to a valvular obstruction in the efferent lymph-vessels). 
tn conclusion, I would raise the question, whether in my case 
the long-continued use of atropine may not have had something 
to do with provoking the glaucomatous attack.