A PECULIAR CASE 
OF 
HERPES ZOSTER OPHTHALMICUS, 
SEROUS IRITIS, 
OR, 
“ OPHTHALMO-NEURITI S.” 
BY 
GEORGE M. GOULD, M.D, 
[Reprinted from The Polyclinic, October, 1888.] A PECULIAR CASE OF HERPES ZOSTER OPHTHALMICUS, 
SEROUS IRITIS, OR “OPHTIIALMO-NEURUTS.” 
GEORGE M. GOULD, M. D. 
[Reprinted from The Polyclinic, October, 1888.] 
but under cocaine I was convinced . that 
the details of the fundus were not visible; 
they seemed obscured by a cloudiness and 
haze, greatest at the papilla and growing 
less toward the periphery where the retinal 
reflex and small vessels seemed normal. 
Vision was of course impaired, letters the 
size of J. 18 being legible with difficulty. 
I failed to elicit any history of a blow or 
injury, and syphilis was I think truthfully 
denied.* The patient had been a healthy 
man all his life, without vicious habits or 
constitutional disease of any kind. 
What was to be the diagnosis ? The ab- 
sence of any symptoms of iritis, either 
due to the exposure to cold or to any 
injury, led me to believe there must have 
been some history of traumatism concealed 
or unknown. I endeavored to ascertain if 
some sliver of metal (he was a worker upon 
brass tubing) may not have penetrated the 
globe or orbit without leaving any trace. 
The second week I asked my friend, Dr. 
Oliver, to examine the eye, and he judged 
there must have been some traumatic injury. 
Astringent and antiseptic collyria kept 
the conjunctiva clean and without secretion, 
but did not in the least lessen its injection. 
I found several dacryoliths ‘in the upper 
palpebral conjunctiva and removed them, 
but neither this nor the most energetic anti- 
phlogistic measures, with paralysis of the 
On July 6th, I was called to see F. P. M. 
, who, it was said, was suffering with 
“severe inflammation” of the left eye. 
His complaint was of a persistent boring 
pain behind and above the eye, and extend- 
ing thence to the vertex of the head. Ques- 
tioned as to the history and cause of the 
trouble, he said that on June 24th he became 
very much heated carrying water in the sun- 
shine, and that immediately thereafter he 
rode in a railway car several miles to the 
city, sitting beside an open window, the 
wind blowing strong and cool upon the side 
of the face affected. The next day his eye 
became intensely congested and red, and 
there was pain, lachrymation and photo- 
phobia. From this time till July 6th, various 
home remedies were uselessly tried, the eye 
and head growing steadily more painful, 
and the conjunctiva continuing very much 
inflamed. I found the eye in the following 
condition: The lids and adjacent parts 
were not swollen; the whole conjunctiva 
was intensely congested and of a bright 
scarlet hue ; there was no pannus, and the 
cornea and anterior chamber were clear. 
The iris to all appearance was normal or 
but slightly hyperaemic. The pupil was 
somewhat contracted, but responded to light 
and darkness fairly well. There was cer- 
tainly no pronounced iritis, the delicate 
striation and reflex of the fibres being clear 
and perfect. There was such great photo- 
phobia and lachrymation that a perfect oph- 
thalmoscopic examination was not possible, 
* The second week of the disease I tried antisyphilitic treat- 
ment for three days, but with such aggravation of all the symp- 
toms of the malady that I hastened to renounce it. 2 
accommodation, gave any relief. Two 
ounces of blood were drawn from the temple 
by leeches, and this was repeated the second 
day afterward; hot fomentations, alter- 
nated twice on the following days with cold, 
slight purgation, etc., etc., left me and my 
patient at the end of three weeks just where 
we were at the beginning. Occasional 
slight increases of the intra-ocular tension 
were promptly reduced by eserine instilla- 
tions, the iris always reacting to either this 
or atropine. The pain behind and above the 
globe continued, and the patient’s nervous 
system was growing unable to withstand the 
loss of sleep. Morphine, chloral and bro- 
mide, hyoscine, and other hypnotics were 
successively tried and in heroic doses, but 
were powerless to give any sleep. There 
were occasional hours of troubled dozing in 
the daytime. 
At the end of three weeks I again asked 
Dr. Oliver to look at the eye, and we then 
discovered nothing new except a few tiny 
flecks upon Descemet’s membrane, which 
led Dr. Oliver to diagnosticate a serous iritis 
(uveitis), and suggest pilocarpine as of pos- 
sible advantage. To this I added antipyrine 
and quinine. The change was almost magical. 
From the second day after instituting this 
treatment the patient was almost entirely 
relieved of pain, and was sleeping soundly 
at night. Convalescence was slow, and 
marked by this peculiarity: within a week 
after the above treatment and crisis, and 
when the eye had nearly recovered its nor- 
mal appearance, the iris began showing signs 
of inflammation, until finally a decided iritis 
was apparent. This, however, disappeared 
under the routine treatment. The iritis 
was attended by no pain or subjective symp- 
toms, and the conjunctiva continued unin- 
terruptedly to clear, while the details of the 
fundus also became more and more distinct, 
the papilla and its immediate vicinity still 
remaining somewhat ill-defined or cloudy. 
The man was to return to work on August 
19th with the conjunctiva and media clear, 
a responsive and normal iris, a somewhat 
hazy papilla, and slightly sub-normal visual 
acuteness. 
I am describing the case and the troubles 
of diagnosis as they arose, and, therefore, 
interject at this point a few words written 
at this time. 
In endeavoring to specialize more accu- 
rately the exact nature of the trouble, I 
have tentatively adopted the hypothesis in- 
dicated by the title ophthalmo-neuritis, or 
peripheral neuritis of the ophthalmic branch 
of the fifth nerve, and wish to call attention 
to the following reasons that have led me 
to do so : — 
At my first examination of the patient I 
carefully examined the side of the face ex- 
posed to the draught of cold air in the car, 
to see if there were any symptoms of facial 
paralysis, but found both motion and sensa- 
tion were normal. But I then learned that 
there had been for two or three days after 
the car-ride, considerable stiffness and ten- 
derness at the angle of the jaw, with some 
shooting pains out upon the face from this 
point.* At this time it had flashed upon 
my mind that the ocular trouble was a 
phenomenon precisely analogous in essential 
cause and nature to that of paralysis of the 
seventh by exposure to cold; but since I 
found nothing of this in half a dozen or 
more of the best treatises on the eye, I 
allowed the thought to partially drop, though 
never entirely giving it up. 
I now return to this view, and believe 
that the affection was essentially a periph- 
eral neuritis of the ophthalmic branch of 
the fifth, the bulbar and retrobulbar portions 
of the optic nerve becoming implicated in 
the inflammatory process, and iritis super- 
vening at a later date and merely secondarily. 
The designation of the disease as an iritis, 
I think a misnomer, since I cannot believe 
* In riding in a car by an open window one rests his hand 
naturally on the side of the face, and thus protects the seventh 
nerve. To this, perhaps, is due the escape from facial paralysis 
in this case. 3 
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 synechise, 
and only at a still later day begin the forma- 
tion of deposits upon the membrane of Des- 
cemet.” DeWecker, in exposing his theory 
that serous 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, 
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. 
* Grae/e, Archiv fur Ophthalmologie, 26-3-62. 
f Traiti Complet d' Ophthalmologic, Tome 11, Fasc. 2, pp. 
280 and 313. 4 
Lastly, we see why pilocarpine would 
relieve the tension of the nerves and adjacent 
parts by withdrawing the serous exudate of 
the perineuritis, and the powerful action of 
antipyrine and quinine would contribute to 
reinstate the interrupted and normal trans- 
mission of the innervation, thus bringing 
about the sudden and happy relief experi- 
enced by the patient. To avoid circum- 
locution, I have therefore coined the term, 
ophthalmo-nenritis, as indicative at once of 
the organ affected and the pathology of the 
disease, and I hazard the query, if many 
cases of so-called serous iritis are not in fact 
due to a peripheral neuritis? The anomalous 
and inexplicable mysteries of that peculiar 
affection would thus be brought to show 
their causal relations and their analogies 
with other facts and other affections. 
PART II.—POSTSCRIPT. 
The preceding pages here stand as they 
were written two days before my patient was 
to return to work. I leave them thus in 
order the better to bring into view the diffi- 
culties of diagnosis, and the lessons derivable 
from them. 
I had up to Aug. 19th kept my patient 
from returning to work because I had in 
daily remembrance a case of facial paralysis 
with ocular complications that I had treated 
one year previously, in which there was an 
almost identical history of exposure to a cold 
draught of air after great heat, and in which 
several weeks after apparent recovery there 
was extensive herpetic eruption over thepes 
anserinus. Reasoning upon analogy, I was 
awaiting herpes zoster ophthalmicus, if my 
diagnosis of ophthalmo-neuritis were correct. 
The disease, it will be remembered, had 
been continuous for thirty-seven days, when 
there was a crisis and, following pilocarpine, 
etc., sudden relief, with an eighteen days’ 
convalescence. I had about concluded that 
there would be no herpes zoster to put the 
seal of certainty upon my diagnosis, when 
it came so suddenly and so severely that 
my pleasure at the proof was speedily for- 
gotten in anxiety lest the eye was to be lost 
after all. In twenty-four hours, lines of 
herpetic vesicles, as if burned with a red-hot 
wire, suddenly appeared along the side of 
the nose opposite the inner canthus, extend- 
ing toward the supra-orbital foramen and 
across the upper eyelid. With this there 
was lighted up a plastic iritis, with circum- 
corneal injection, cloudy aqueous, etc. 
There was no herpes cornege or conjunc- 
tivae. As there was no pain at all with all 
this, the patient did not come to me for 
some twenty hours after the eruption began 
appearing, and yet in this time the iris 
border had already formed resisting attach- 
ments to the lens-capsule. These I suc- 
ceeded in breaking away. Other slight 
lines of herpes subsequently appeared on the 
lower lid and at the outer canthus. The four 
weeks of convalescence that followed were 
interrupted by a relapse in which a slight 
iritis appeared, and a muco-purulent con- 
junctivitis, with an inflammation of the skin 
of the lids and parts about the eye, supplied 
by the first branch of the fifth nerve. There 
was no positive eruption, though there was 
great congestion, the skin at one time 
assuming a smooth, shining appearance, and 
later a parched, wrinkled look. Under 
careful treatment this within a month at last 
passed away. 
Herpes zoster ophthalmicus !—This was 
the masked enemy I had been fighting for 
fifty-five days ! According to the existing 
classification and nomenclature, the affection 
must be called by this name. And yet what 
a commentary upon our pathology and 
symptomatology, to call a disease after a 
slight, unimportant, painless, widely-sepa- 
rated and superficial skin symptom, that 
appears after the real disease has been going 
on for fifty-five days! I have, in review of 
the literature of herpes zoster ophthalmicus, 
found one case in which the herpetic symp- 
tom did not appear for three months. 
That, from the analogy of one case of 5 
herpes zoster in facial paralysis, I should 
have suspected the true nature of this ocular 
trouble; and, though temporarily leaving 
it in abeyance, that I should at last and 
definitely have returned to my diagnosis 
long before proof was forthcoming,—this 
shows how well it is to let no theories or 
authorities, no scientific classifications or 
routine nomenclatures stifle one’s own per- 
ceptions of facts or analogies, or one’s own 
reading of the symptoms of a concrete 
disease. Pathological facts constantly non- 
suit the harnessings of the best pathological 
theories. In my case, also, a correct diagno- 
sis was unexpectedly of immense practical and 
prognostical value; since, had the patient 
returned to his business when it apparently 
seemed safe for him to do so, it would have re- 
sulted in, to him, important financial compli- 
cations when the herpes and iritis did appear. 
I do not here enter upon the question as 
to the intimate pathology of the lesion, 
whether it was interstitial or parenchyma- 
tous, etc., nor as to the order in which 
certain peripheral branches were affected 
first, while others were comparatively free 
from the morbid process, and why some 
were implicated only late in the history of 
the malady. I do not understand exactly 
why the optic nerve was affected throughout, 
and why the uveal tract was implicated so 
late, and why the cornea remained undis- 
turbed throughout. That the vaso-motor 
fibres, which, according to Buzzard, are the 
most infrequent examples of peripheral 
neuritis, were most severely and early 
attacked, seems evident. The double re- 
lapses or lighting up of iritis intercurrently 
with the skin lesions is worthy of notice, 
and as taking place during the convales- 
cence, seem to be trophic phenomena con- 
nected in some way with the repair and 
healing of the diseased nerve fibres. 
RESUME. 
A case of monocular disease with abrupt 
and severe onset, appearing in a strong, 
healthy adult man, the day after overheat- 
ing and exposure to a cold draught of air 
upon the side of the face. The symptoms, 
from the beginning and continuing for 
thirty-seven days, were: a persistent and 
boring pain, behind and above the eye, ex- 
tending thence to the crown of the head ; a 
sleeplessness not conquerable by hypnotics ; 
a deep injection of the conjunctival and 
episcleral capillaries; a cloudiness and ob- 
scuration of the papilla and central portion 
of the fundus oculi; a slight tendency to 
excess of intraocular tension ;—the eye in 
every other respect normal, without note- 
worthy implication of the iris, cornea, or 
refractive media. In thirty-six days appear- 
ance of symptoms of serous iritis ; adminis- 
tration of pilocarpine with antipyrine and 
quinine; immediate and sudden disappear- 
ance of all pain, followed by a return of the 
eye nearly to its normal condition, barring 
slight obscuration of the papilla and a sub- 
normal acuteness of vision. In fifty-five 
days from the onset of the affection, sudden 
appearance of herpes zoster ophthalmicus, 
affecting the side of the nose and the eye- 
lids, especially the upper, with an intercur- 
rent typical plastic iritis. Convalescence, 
interrupted by a relapse of slight iritis, and 
conjunctivitis, and a dermatitis of the parts 
supplied by the ophthalmic branch of the 
fifth nerve. 
According to the current nomenclature 
this aberrant form of disease must be classed 
as a case of herpes zoster ophthalmicus, but 
since the real disease was undoubtedly a 
peripheral neuritis, due to cold, of the oph- 
thalmic branch of the fifth, and that it had 
lasted fifty-five days before one of its very 
minor and inconsiderable symptoms, a 
herpetic eruption of the skin, appeared, it 
seems proper to ask if a more fitting appella- 
tion should not be given this formidable 
affection. As a more expressive name, and 
one truer to the pathological facts, the term 
ophthalmo-neuritis is tentatively suggested. 
In a future paper I propose to review the 6 
literature of ophthalmic herpes zoster, with 
the design of more plainly bringing out the 
typical characteristics of the disease, of ren- 
dering the diagnosis more quickly recog- 
nizable, and the therapeutics more effective. 
In the meantime, from my case, I offer the 
following 
CONCLUSIONS. 
i. Ophthalmo-neuritis is an inflammation 
of the nerves of the ophthalmic branch 
of the fifth, with implication of its vaso- 
motor and trophic fibres, and possible ex- 
tension of the inflammation to the optic 
nerve. 
2. It may be caused by exposure to a cold 
draught of air, and is probably similar in 
essential nature to the lesion resulting in 
facial paralysis when the seventh nerve is 
affected from the same cause. 
4. The symptoms may be intense pain, 
lachrymation, photophobia, conjunctivitis; 
later, those of serous iritis, and, still later, 
those of plastic iritis and herpes zoster oph- 
thalmicus. 
4. Pilocarpine may give relief from the 
long-continued pain and tension of the early 
stages of the affection. 
ng S. Seventeenth St., Phila. MIXED ASTIGMATISM, THE RESULT OF 
SEVERE INFLAMMATION OF 
AN EYE. 
To the Editor of The Polyclinic:— 
Permit me to add an interesting fact con- 
nected with the case of Herpes Zoster Ophthal- 
micus described in your last issue, and which I 
have discovered since sending you the report. 
The eye has entirely recovered and presents a 
normal appearance in every respect. The skin 
of the lids and adjacent parts is without 
a trace of the usual scars, due to the use, during 
the herpetic inflammation, of softening, anti- 
septic and healing ointments. There are no 
iritic adhesions, and the fundus is clear and 
normal. But I have been interested to find 
that during and since the convalescence there 
has been an incre;t$lng amblyopia, due, as I 
first supposed, to sdme intimate lesion of the 
retina or nerve consequent upon the severe 
inflammation through which the eye had passed. 
The right, or unaffected eye has throughout 
preserved its perfection of visual acuteness, 
and to-day registers and J. i at the usual 
distances, without glasses. During the conva- 
lescence the vision of the inflamed eye was at 
one time under a mydriatic. Later it was 
likewise with paralyzed accommodation. At 
this time I only made a hurried test, owing to the 
weakness of the eye, but found that Sph.—1.50 
D. 3 cyl. + 1.25 &■< Ax. 1800, brought the 
vision up to §§.' To-day, with a perfectly 
recovered eye, I find vision -gfe and J. 14, with 
difficulty. The amblyopia is now shown to be 
entirely due to refractive errors. I have tested 
the refraction both without and with paralysis of 
the accommodation, and find it almost iden- 
tical. Sph. —1.25 D. 3 cyl. + 3.75 D., Ax. 1800 
gives V. f§, and J. 1 at 12 inches, with ease. 
The fact that the patient is perfectly certain 
that the eyes, before his illness, were equally 
good, combined with the demonstrated increase 
of the refractive error during convalescence, 
shows that, as a result of the ordeal through 
which the eye has passed, there has been an 
increase of the antero-posterior diameter of the 
globe, and changes in the corneal symmetry, 
resulting in the mixed astigmatism indicated by 
the combined lens before mentioned. 
I am, Sir, very respectfully yours, 
George M. Gould. 
rig S. 17th St., Philadelphia, 
Nov. 6th, 1888.