KERATITIS BULLOSA. 
By C. W. TANGEMAN, Cincinnati, Ohio, 
ASSISTANT TO THE CHAIR OF OPHTHALMOLOGY AT THE MEDICAL COLLEGE OF OHIO. 
THIS disease, though not of very frequent occurrence, 
has been described by a number of observers in the 
last century. Cases have been observed and reported from 
time to time, and the subject has received considerable at- 
tention, experimentally, at the hands of Prof. Leber, and 
yet the etiology of this disease is quite obscure. The 
scarcity of clinical material has made it difficult to study 
the affection with any degree of satisfaction. Experiments 
on the eyes of animals have yielded but few data, except to 
disprove the erroneous theory of Landesberg, who advanced 
the idea that the formation of vesicles on the cornea is 
purely mechanical, caused by a force from behind, as in in- 
creased intra-ocular pressure. It is now definitely fixed that, 
no matter how great the intra-ocular pressure, the fluid in 
the anterior chamber does not cause oedema of the cornea, or 
is not permitted to pass through the membrane of " Desce- 
met " unless the surface be broken. In a large number of 
the reported cases of "keratitis bullosa" there was neither 
increased intra-ocular pressure nor inflammation of the uveal 
tract recorded.1 Saemisch makes an infiltration of the pa- 
renchyma of the cornea the first stage in this disease. He 
says that all the difference there is between parenchymatous 
infiltration of the cornea and keratitis bullosa is that in the 
latter, some time during the course of the disease, there is a 
formation of large vesicles, larger than phlyctenular vesicles, 
and not so round or regular in shape. Graefe,5 when mak- 
ing a microscopic examination of the anterior wall of the 
described vesicle, finds that not only the epithelial layer, 
but also the anterior elastic membrane and some fibres from 
1 Graefe and Saemisch : Handb. d. Ges. Augenhk. 
2 Graefe : Arch. Ophth., ii., I, 206. 
Reprinted from the Archives of Ophthalmology, Vol. xvii., No. 1, 1888. 93 
Keratitis Bullosa. 
the parenchymatous layer of the cornea, is separated to 
make up the covering of the vesicle. Possibly the smallest 
number of cases would show an involvement of the cornea 
to that depth. Usually, as Schweigger1 states, he never 
found that more than the anterior epithelial layer was sepa- 
rated in this disease. Bullous keratitis must be differen- 
tiated from the various forms of vesicular keratitis or herpes 
cornea, which may occur without any previous inflammatory 
disturbance. It is safe to say that we have to deal with a 
separation of the superficial layer only in all of these vari- 
ous forms of inflammation ; the contents are the same, but 
the condition of the cornea and the circumstances under 
which each form is developed are different. Warlemont, 
McKenzie, and others have described this disease as dropsy 
of the cornea,-a formation of vesicles or blebs, due to an 
escape of fluid from the anterior chamber through the 
corneal tissue. While this theory has been disproven, 
nothing satisfactory has been substituted. Since a few cases 
have been reported of keratitis bullosa in glaucomatous 
eyes, the tendency has been to connect the etiology of the 
two diseases. Degenerative changes of the epithelial cells, 
causing an enlargement of the intercellular spaces, has most 
recently been advocated as the chief process that is going 
on in the corneal tissue, which looks so much like a paren- 
chymatous inflammation of the cornea. Michel reports 
cases where he observed the formation of vesicles quite 
large on a cornea otherwise perfectly healthy. 
The patient that came under the writer's observation at 
Prof. W. W. Seely's clinic is of special interest, since the 
vesicles appeared on both eyes simultaneously, and on an 
otherwise perfectly healthy cornea. 
Mr. B., set. thirty, laborer, white, robust and healthy, com- 
plained of a disturbance of his sight. Since the past week he had 
suffered acute attacks of pain, which seemed to get better one 
day and worse the next. A careful examination of his eyes 
showed three or four vesicles on each cornea, quite large, filled 
with a clear fluid. The patient said he had had previous attacks 
of a similar nature, and he had seen "blisters" form on the sight, 
1 Schweigger : Handbuch, 1873. C. H. Tangeman. 
94 
that would pass away again. The cornea showed distinct traces 
of an apparently superficial abrasion. Aside from these changes 
nothing abnormal could be found about the cornea. The chief 
complaint was an intense burning sensation and some redness of 
the ocular conjunctiva. The tension was normal, and the depth 
and contents of the anterior chamber looked natural. The patient 
was not suffering from any constitutional affection, but gave a 
distinct malarial history or tendency. 
On the second day later, he presented himself again, and some 
new bullae had formed. The patient was now put on large doses 
of quinine, with the effect of removing all symptoms of irritation, 
and preventing a recurrence of the vesicles on the cornea. The 
patient was kept under observation for some time, but there was 
not even a tendency to a return of the symptoms above recorded. 
Here, now, we have a case of a rare disease, carefully- 
watched, with an intermittent tendency, being absolutely- 
cured upon the administration of an antiperiodic. Does 
this indicate anything? Graefe, Schultze, Saemisch, and 
others have recorded cases with distinct periods of in- 
termission, but fail to speak of the possibility of malaria 
having any etiological connection with this affection. In 
the above case all of the diseases usually given as causative 
of vesicular keratitis, viz., glaucoma, iritis, ichthyosis, inflam- 
mation of the uveal tract, degeneration of the corneal epi- 
thelium, corneal infiltration and enlargement of the inter- 
cellular spaces, engorgement of the lymph spaces, increased 
intra-ocular pressure, or a mechanical force, were absent. 
Hansen some time since described a case of intermittent 
vesicular keratitis, but insists that it was caused by trauma 
to the corneal epithelium. 
How these vesicles should occur on the cornea due to 
malaria is difficult to say, yet it would be no more impos- 
sible than when they follow vaso-motor disturbances 
(Michel), or when we have a serous effusion into the vitre- 
ous (Seely1), or, finally, in the case reported by Perlia,2 
where the formation of the vesicles was due to vaso-motor 
changes5 caused by migraine. 
1 Transactions of the Amer. Ophth. Soc., 1883. 
' Zehender : Monats. Bl., 1888.