THE TREATMENT OF COMPLICATED 
ULCERS OF THE CORNEA. 
A PAPER READ BEFORE THE FORTY-SEVENTH ANNUAL MEETING 
OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA. 
BY 
CLARENCE A. VEASEY, A.M., M.D., 
Adjunct Professor of Diseases of the Eye, Philadelphia Polyclinic; Demonstrator 
of Ophthalmology, Jefferson Medical College; Chief Clinical Assistant 
to the Ophthalmological Department, Jefferson Medical 
College Hospital; Consulting Ophthalmologist, 
Philadelphia Lying-in Charity, etc. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, JULY 15, i8Q7- 
DETROIT, MICH. I 
GEORGE S. DAVIS, PUBLISHER. 
1897. THE TREATMENT OF COMPLICATED 
ULCERS OF THE CORNEA. 
By Clarence A. Veasey, A.M., M.D. 
In a former paper* it was suggested that 
for all practical purposes corneal ulcers be 
divided into two great classes, the simple 
and the complicated. By a simple ulcer is 
meant one that makes its appearance as a 
small, superficial, grayish lesion of the cornea, 
with no marked tendency to spread and with 
slight inflammatory symptoms such as injec- 
tion of the conjunctiva, moderate lacrima- 
tion, and perhaps more or less intolerance of 
light. By a complicated ulcer is meant one 
that is more or less extensive, that shows a 
disposition to spread rapidly and involve 
other portions of the cornea than that first 
affected, and which produces all of the symp- 
toms found in connection with a simple ulcer 
in a markedly exaggerated form. In the 
paper above referred to the author discussed 
the treatment of the first class, or simple cor- 
neal ulcers. In the short time at his disposal 
to-day he will endeavor to discuss briefly 
those methods of treatment of the second 
class, or complicated corneal ulcers, that have 
proved to be the most satisfactory in his own 
work. 
A corneal ulcer ordinarily presents itself 
* The Treatment of Simple Ulcers of the Cornea. 
The Philadelphia Polyclinic, June 22, 1895. 2 
as a small grayish spot, the surrounding por- 
tion of the cornea being more or less hazy. 
This haziness may be a solid infiltration in 
all directions around the ulcer, or the latter 
may be a central point from which numerous 
striae pass in various directions. The eye- 
ball is more or less injected, there is exces- 
sive lacrimation, intolerance of light, and 
pain, the latter sometimes being out of pro- 
portion to the severity of the lesion owing to 
the distribution of nerves in the anterior 
layers of the cornea. 
In the treatment of complicated corneal 
ulcers we begin as in the simple cases, by 
searching for the cause and removing it if 
possible. We look for foreign bodies either 
in the ulcer itself or upon the under surface 
of the lids where they may have lodged, and 
by constant scraping of the cornea as the lids 
were opened and closed have caused a denu- 
dation of the corneal epithelium, resulting in 
ulceration. In the same way misplaced cilia 
and small growths frequently cause corneal 
ulceration. But by far the most frequent 
cause, especially in children, is intranasal 
disease extending upward through the lacri- 
mal ducts into the conjunctiva and thence 
to the cornea; and in all cases in which this 
condition is found the treatment must be 
directed towards it as well as towards the 
ulcer itself. 
In the local treatment it is better to begin 
with the employment of those remedies found 
to be of the greatest service in the treatment 
of simple corneal ulcers, as many of the more 
complicated cases yield to these alone. They 
are as follows: 3 
1. Moist Heat.-In applying moist heat to 
the eye the object is to keep up a continuous 
uniform high temperature for some time at 
regular intervals, and this is done in the fol- 
lowing manner: Several small pieces of lint 
'or flannel about three inches in diameter are 
dipped into water as hot as the hand can be 
held in for an instant, or at the temperature 
of i2o° F., and laid on the closed eyelids, 
three or four thicknesses being employed, as 
the heat is better retained in this way. In 
from one to one and one-half minutes these 
are replaced by others, more hot water being 
repeatedly added to keep up the temperature. 
Heat applied in this manner should be em- 
ployed for fifteen to thirty, or even sixty, 
minutes at a time, and should be used from 
three to eight times a day according to the 
virulence of the ulcer. 
2. Cleansing Solutions.-Immediately after 
using the moist heat, and between the ap- 
plications if there be much discharge, the 
conjunctival cul-de-sac and the cornea should 
be thoroughly cleansed by means of some 
soothing lotion. For this purpose a satu- 
rated solution of boracic acid, or a solution 
of mercuric chloride (1:6000), answers the 
purpose very well, though solutions of other 
remedies may be preferred by others, as 
chlorine water, cyanuret of mercury, per- 
manganate of potash, or formaldehyde. The 
latter drug in the strength of i part to 
4000 has proved of the greatest service in 
those varieties of corneal ulcers having a 
tendency to spread with unusual rapidity 
and complicated with hypopyon, but must 
be employed at frequent intervals, namely, 4 
every hour or two. Whatever solution is 
employed should be warm, and this tem- 
perature is readily secured by standing the 
bottle containing the solution in a basin of 
hot water for a'few moments before using, 
care being taken to test the solution on the 
back of the hand before placing in contact 
with the eye. 
3. Instillation of Atropine or Eserin.-A 
drop of a solution of the sulphate of atropine 
(four grains to the fluidounce) is dropped on 
the cornea two or three times a day, provided 
the ulcer be situated near its center. This 
combats any impending inflammation of the 
iris and reduces the general irritation of the 
eye, in this manner acting favorably upon 
the ulcer itself. But should the ulcer be 
situated near the margin of the cornea a 
drop of a solution of the sulphate of eserin 
(one-sixth or one-fourth of a grain to the 
fluidounce) may be employed instead. The 
latter promotes healing by stopping the mi- 
gration of the white blood-corpuscles, by 
promoting absorption through dilatation of 
the ciliary vessels, and by reducing intra- 
ocular tension if this be elevated. It should 
be employed from three to six times a day, 
and as it possesses a tendency to cause con- 
gestion of the iris and ciliary body it is 
better during the time of its employment to 
counteract this tendency by instilling at night 
a drop of the solution of atropine. Should 
there be at anytime any complication involv- 
ing the iris or ciliary body the eserin must 
be discontinued and the atropine employed 
in its place. 
4. Protection.-The eye should be pro- 5 
tected by dark glasses or a bandage. If much 
discharge is present it is evidently improper 
to dam it up in an already inflamed eye; in 
such a case dark glasses being preferable. If 
the amount of the discharge be small a well- 
applied bandage will materially assist in the 
reparative process, it being left off long 
enough for the application of the other reme- 
dies. It should be applied lightly but firmly, 
and should keep the lids closed and at rest 
without making any pressure on the eyeball, 
unless this should be required. It also keeps 
out such extraneous matter as dust, and should 
be worn until the floor of the ulcer is covered 
with epithelium, which protects it from ex- 
ternal irritation. 
Should the ulcer seem disposed to spread 
rapidly, to become more virulent in action, 
and to involve greater destruction of the 
corneal tissue in spite of the faithful em- 
ployment of the above-mentioned remedies, 
our measures for checking its progress 
and producing resolution must necessarily 
be somewhat more severe. In the order in 
which they are employed they are as fol- 
lows: 
5. Curettement.-The ulcer may be curetted 
by an instrument specially devised for this pur- 
pose, or if this is not at hand it may be done 
more or less perfectly with a sterilized probe 
on the end of which has been wrapped a wisp 
of aseptic absorbent cotton. The cornea is 
first anesthetized with a solution of cocaine, 
or eucaine, after which a drop of a two-per- 
cent. solution of fluorescin is instilled and the 
excess washed off, this substance having the 
power of coloring the ulcerated portion light 6 
green, while the remaining portion of the 
cornea having its epithelium intact remains 
unchanged. The use of this preparation, 
therefore, is of decided advantage, as it maps 
out for the operator the exact portion to be 
curetted and enables him to avoid injuring 
the healthy parts of the cornea. The sides 
and back of the ulcer are relieved of the 
slough as far as possible, and after a drop of 
the atropine solution is instilled some finely 
powdered sterilized iodoform is dusted upon 
the cornea, and a light pressure bandage ap- 
plied. This is repeated if necessary on the 
succeeding day. Recently the author has also 
obtained some excellent results from the use 
of finely powdered acetanilid employed in 
place of the iodoform. 
Hydraulic curetting as a method of treat- 
ment has recently been suggested, and it is 
carried out by having a receptacle containing 
the antiseptic solution to be employed held 
on a higher level than the eyes, while a nozzle 
with a fine point, connected with the former 
by means of a rubber tube, directs the stream 
for some minutes against the ulcer. 
6. Topical Application of Chemicals. - If 
after a fair trial of the curette, the iodoform 
and the bandage, together with the use of 
moist heat, atropine, or eserin, according to 
the indications already stated, the ulcer 
should continue to grow worse, it is best to 
attempt to bring about a healthy condition 
by the application of some one of the chemi- 
cal agents used for this purpose. The ulcer 
is first curetted in the manner described and 
the chemical agent is brought in contact with 
every portion of it by means of a wisp of 7 
cotton wrapped on a pointed probe, or stick, 
previously sterilized. For this purpose one 
of the simplest as well as one of the best 
stimulants is the tincture of iodine. Stronger 
agents, actually cauterizing the parts, are 
solutions of silver nitrate (ten to thirty grains 
to the fluidounce), liquid carbolic acid, and 
strong solutions of bichloride of mercury 
(1:500). In applying these care must be 
taken to touch only the affected parts, as an 
application to the healthy cornea would result 
in an opacity of greater or lesser density; 
and as an opacity always results from corneal 
ulceration, except the most superficial, it must 
be our object to keep it as small as possible. 
After the application of the chemical agent 
the eye is treated as after curettement. 
7. The Actual Cautery.-Among the more 
severe remedies at our disposal, when those 
previously referred to fail to check the prog- 
ress of the ulcer, is the actual cautery, and in 
very few cases does the proper use of it fail 
to prevent the further extension of the dis- 
ease. In the execution of this method of 
treatment we may employ the elaborate cau- 
tery outfits of the shops, if they are at hand, 
but a simple as well as most effective cautery 
probe can be had by inserting a piece of 
medium-sized platinum wire into the so-called 
" universal " laryngoscope handle. An as- 
sistant holding an alcohol lamp near the head, 
all draughts being avoided so that the flame 
will be steady, the end of the probe is brought 
to a white heat and quickly transferred to the 
ulcerated portion of the cornea, this having 
been mapped out by the use of fluorescin 
after the cocainization of the eye and the 8 
eyeball being firmly held with the fixation 
forceps. As before stated the sides and base 
of the ulcer must be thoroughly cauterized, 
but care must be taken to avoid injury to the 
healthy tissue. Properly applied the actual 
cautery leaves a scar no larger than, if as 
large as, would have been the case if it had 
not been used; but improperly applied it 
increases the size of the corneal scar and 
therefore decreases in proportion the visual 
acuity. The eye is dressed as after the appli- 
cation of the chemical agents. 
If at any time during the treatment of the 
disease the cornea threatens to perforate, as 
indicated by a slight bulging of the base of 
the ulcer, a bandage is evenly applied, making 
gentle but firm pressure; and if in spite of 
this the bulging continues to increase it is 
better to anticipate perforation by performing 
paracentesis of the anterior chamber through 
the floor of the ulcer itself if the conditions 
are favorable. 
8. Intranasal Treatment.-In those cases 
having considerable discharge of mucus or 
muco-pus from the nares it is well to cleanse 
the parts several times a day with a mildly 
alkaline solution, such as Dobell's, one-fourth 
strength, and to follow with the insufflation 
of some of the following powder: 
B Pulverized camphor, 30 grains; 
Pulverized aristol, IO grains; 
Pulverized menthol, 20 grains; 
Bismuth subcarbonate, 2 drachms. 
Mix. 
If the mucous membrane on the turbinated 
bones be much swollen it may be sprayed 
with a solution of antipyrin (ten to thirty 9 
grains to the fluidounce), the parts then 
cleansed with the alkaline solution, and this 
followed by the spray of an oily preparation: 
3 Pulverized camphor, 30 grains; 
Pulverized menthol, 30 grains; 
Liquid petrolatum, 1 fluidounce. 
Mix. 
The topical application of the compound 
tincture of benzoin has also been found of 
much benefit in these cases. 
If there is any gross lesion such as a 
polyp, a spur, or septal deviation, it must be 
attended to as early as possible, and this also 
applies to any disease of the lacrimal duct. 
9. Constitutional Treatment.-As with dis- 
ease manifesting itself in any other part of 
the body the constitution must be put in the 
best possible condition. Instead of confining 
patients to a darkened room, as a rule it will 
be better to allow them to pass several hours 
a day in the open air, the eyes being prop- 
erly protected. Any particular diathesis that 
is present must be especially attended to, and 
in large, progressive ulcers the system must 
be supported by stimulants, and quinine ad- 
ministered. In the beginning it is advisable 
to give a brisk purgative followed by a sa- 
line draught. The diet must be digestible 
and nourishing, all sweets being interdicted. 
If pain is severe and continuous and not 
relieved by the means suggested above, the 
antineuralgics or even opiates are indicated. 
In the preceding remarks those methods 
of treatment that have been of the greatest 
use to the author in the management of such 
cases are given in the order in which they 
are usually employed. It is impossible in the 10 
brief time allotted to this paper to discuss 
the many complications that may arise during 
the treatment of a given case. No fixed rules 
can be made, but a general plan has been out- 
lined, to be modified as emergencies demand. 
Many other methods of treatment have 
been advocated by various surgeons, but 
brief mention will be made of only one, viz., 
the subconjunctival injections of solutions 
of mercuric chloride. As stated elsewhere, 
personal experience in the employment of 
these injections for the treatment of ulcera- 
tive disease of the cornea has not given to 
them the position of value to which they have 
been assigned by many ophthalmic surgeons. 
Experience in the treatment of a large num- 
ber of cases during the past three years has 
shown that injections of a solution of so- 
dium chloride beneath the conjunctiva prove 
equally as beneficial as injections of a solu- 
tion of mercuric chloride, and that neither of 
them is of much value in the treatment of 
this class of cases. 
To recapitulate, the treatment of compli- 
cated ulcers of the cornea should be carried 
out in the following order: 
1. Examine thoroughly the conjunctiva, 
the lacrimal ducts, the nares and naso-phar- 
ynx, as well as the cornea itself, and if any 
abnormal condition be found that is either 
the primary cause of the ulcer or that is keep- 
ing up the condition, direct the treatment 
against it as well as against the ulcer itself. 
2. Employ moist heat by means of the 
local application of pieces of lint or flannel 
wrung out in hot water at a temperature of 
i2o° F. from fifteen to sixty minutes at a 11 
time, repeating at intervals varying from two 
to four hours, according to the virulence of 
the disease. 
3. Cleanse the ulcer and the conjunctival 
cul-de-sac with some warm antiseptic solu- 
tion immediately after the employment of 
the moist heat, and between the times of its 
employment if there be much discharge. 
For this purpose may be used a saturated so- 
lution of boracic acid, a solution of bichloride 
of mercury (1:6000), or a solution of formal- 
dehyde (1:4000). 
4. Instil a drop or two of a solution of 
atropine (four grains to the fluidounce) once 
or twice daily if the ulcer be central; but if 
it be peripheral, a solution of eserin (one- 
sixth of a grain to the fluidounce) may be 
employed from three to six times during the 
day, and the atropine solution instilled once 
at night. 
5. The eye must be protected by dark 
glasses or an evenly and lightly applied band- 
age. As a rule the former should be used in 
those cases in which there is considerable 
discharge, the latter in the cases in which 
very little discharge is present. 
6. Should the above means fail to check 
the progress of the ulcer it should be curetted, 
and after dusting on its surface some iodo- 
form, previously pulverized and sterilized, a 
bandage should be applied. 
7. Should the ulcer continue to spread, 
after being curetted it should be touched 
with some one of the chemical agents em- 
ployed for the purpose. Of these the tincture 
of iodine, liquid carbolic acid, and silver 
nitrate (the latter in the strength of ten to 12 
twenty grains to the fluidounce) seem to be 
the best. 
8. The actual cautery should be applied 
after the previously described remedies have 
been employed without beneficial result, or 
even before these have been used if it be 
seen that the ulcer has assumed a malignant 
type-that is, if the cornea is becoming so 
rapidly involved that the destruction of all, or 
a large portion, of its tissue is threatened. 
9. Any unhygienic condition, dietetic error, 
or constitutional diathesis should be corrected. 
47 North Seventeenth street. APRIL 16, 1896. 
, WHOLB SERIES. VOL XX. No. 4. , THIRD SERIBS. VOL XII. 
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