In ophthalmic practice three disease manifestations are encountered to which the name "keratitis punctata" has been applied. Two of these are affections of the cornea, the third is not; that is to say, the primary lesion is not corneal. They are as follows: (a) keratitis superficialis punctata, in which, in general terms, numerous small punctiform or linear spots appear below Bowman's membrane, the overlying cornea being slightly hazy and the epithelium a little elevated; (b) keratitis punctata

more »

... vera or syphilitica of Mauthner, in which circumscribed pinhead-sized, grayish spots appear in the parenchyma of the cornea, and, moreover, in its various layers; the iris is not involved. Constitutional syphilis is the etiologic factor. To distinguish it from the preceding manifestations Fuchs suggests the name "keratitis punctata profunda." (c) Keratitis punctata, in which a notable manifestation consists of a precipitate of opaque dots on the posterior elastic lamina of the cornea, generally arranged in a triangular manner, with apex pointing upward, and which from the beginning may be or may not be associated with the signs of iritis. To this last-named condition the older writers gave the names "aquo-capsulitis" and "hydro-meningitis," because it was believed that it represented a disease depending on an inflammation of a hyaloid membrane, which was supposed to line the anterior and posterior chambers as a serous sac and which was connected with the hyaloid of the vitreous. With the belief that the disease depended on a specific participation of the membrane of Descemet in its lesions, arose the name "descemetitis," which is still commonly employed. To those cases in which this punctate deposit on the posterior lamina of the cornea is associated with an iritis, without great tendency to form synechia?, with a deep anterior chamber and with a disposition to increased intraocular tension, the .name "serous iritis" has been and is still commonly given, but, as De Wecker very forcibly objects, the inflammatory product of a serous iritis is not of a serous nature, but is essentially cellular. The iris suffers secondarily from this cellular infiltration which is communicated to all the neighboring parts, the sclerotic, the cornea and the choroid. The points of departure of this cellular inundation are the lymphatic spaces of the eye, and he contends, therefore, that a serous iritis represents a lymphangitis anterior of the eye, having its principal situation in the pericorneal lymph spaces. Long ago Von Arlt noted that in a certain number of eyes with punctate deposits on the cornea inflammatory changes in the iris are practically absent and the pupil Read at the Fifty-third Annual Meeting of the American Medical Association, in the Section on Ophthalmology, and approved for publication by the Executive Committee : Drs. Frank Allport, H. V. W\l=u"\rdemannand J. A. Lippincott. dilates readily. These cases he attributed entirely to cyclitis. The cyclitic origin of the disease has been strongly maintained by E. Treacher Collins, especially after his discovery of the glands of the ciliary body, his belief being that the so-called serous iritis is primarily a catarrhal inflammation of these glands. The secretion of these glands, he maintains, becomes augmented, causing increase in the aqueous humor and deepening of the anterior chamber. The aqueous becomes altered in character, contains leucocytes, pigment cells and fibrin, and these formed elements gravitate and are deposited on the lower portion of the posterior face of the e%rnea. Therefore, it has been suggested that the disease should be named "serous cyclitis," or "iridocyclitis." It has, however, been noticed by many that when the characteristic punctate deposits appear upon the posterior surface of the cornea, if the media are sufficiently clear, recent patches of choroiditis can often, perhaps always, be found in some portion of the fundus. Particularly good studies of this association have been made in England, beginning, I think, with Hill Griffith's observations more than fifteen years ago. He believed that the dots on Descemet's membrane were formed in the choroid, set free in the vitreous and carried by the nutrient currents of the eye to be deposited on the back of the cornea. His view necessitated the admission that the suspensory ligament was permeable to solid particles. The choroidal origin of so-called descemetitis, however, is much older than this. For example, Von Graefe himself described in 1856 the association of choroidal lesions with this condition, and we find Schweigger stating that inasmuch as the ligamenturo pectinatum sinks into the anterior part of the ciliary body, it may be easily understood how the epithelium upon the membrane of Descemet may become affected by an extension of disease from the choroid without any participation by the iris, and he goes on to describe a case in point, the choroidal disease having been situated in the macular region. I mention these facts because quite recently a good deal has been written on this subject as if the association of this condition with choroidal disease was a new discovery. It is well known that not only in so-called serous iritis, but in all varieties of iritis, corneal lesions are always demonstrable by careful examination with a suitable corneal loup in the form of infiltrations in the substantia propria, dot-like deposits on Descemet's membrane, and striations in the posterior corneal layers. These have been well described and classified by Dr. H. Friedenwald. There is, however, one fairly constant clinical picture, which is, in a sense, characteristic, to which the names previously recited, all of which are more or less inexact and misleading, have been applied, viz., a deposit of variously-sized and colored dots, arranged usually in a triangular manner on the posterior layer of the cornea; an anterior chamber, sometimes deep and sometimes of ordinary depth; generally, but not constantly, iritis and cyclitis; hyalitis, and practically always some form of choroiditis, the last-named conditions being the primary lesions in most of the cases. In perfect examples there is reason to believe that the entire uveal tract is more or less involved, and hence the name uveitis is appropriate. In general terms, the causes of uveitis may be diathetic, toxic or infectious. Thus we have causes depending on certain constitutional diseases, for example, rheumatism, gout and diabetes; on specific infectious diseases, for example, influenza, syphilis, gonorrhea, tuberculosis and scrofula, that is, tuberculosis of the Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/06/2015