Swelling and redness of the conjunctivae and eyelids, associated with photophobia and hypersecretion of tears, are not rare in connection with latent supra orbital neuralgias.
In addition, some writers claim that there is a specific conjunctivitis palustris, which comes and goes with the fever paroxysm, and which may occur alone as a latent form. There is in these cases only a hyperemia, not an inflammation, and the symptoms consist in redness, photophobia, hypersecretion of tears, with sometimes edema of the conjunctivae and lids. Pain is wanting. The affection is usually unilateral (Puccinotti, Griesinger, M. Raynaud, de Schwei nitz, L. Raynaud, and others). Baylot observed several such cases during an epidemic in Biskra; Verdan, in Algiers. Malarial scleritis and periscleritis palustris are mentioned by de Schweinitz.
The cornea sometimes participates in the infection through the herpes which accompanies the fever, in that vesicles occur simultaneously on the nose and the eyelids (Godo).
Different forms of keratitis have likewise been associated with malaria , as, for instance, the interstitial keratitis of cachectics, by Levrier, Sedan, a dendritic keratitis, possibly arising from herpes cornea, by Kipp. The latter observed in America 120 cases of this kind. In 90 per cent, of the cases the keratitis came on several days after the paroxysm. At the beginning small prominences appeared on the cornea, which broke down and gave rise to ulcers. These were serpiginous in form, with small prolongations. Hypersecretion of tears, photophobia, and pain were also present.
Similar observations have been made by Arlt, Poncet, Sedan, and others. In Millingen's cases (Constantinople) the ulcer, as well as its surroundings, was anesthetic.
Necrosis of- the cornea in neglected cachectics has been reported by Fayrer.
Iritis was observed by Brown, especially in cases that suffered during the acute infection from hemicrania and attacks of vertigo.
Even iritis with hypopyon has been ascribed to malaria (Staub, Quaglino). Tangemann described one case of iritis associated with intense pain, conjunctivitis, and photophobia, which did not react to atropin and was cured by quinin.
They are usually, though not always, dilated during the paroxysms. Inequality of the pupils has been observed.
Visual disturbances produced by lesions of the fundus are, on account of their frequency and their more evident connection with malaria , more important and interesting.
Poncet assures us from his wide experience that every visual disturbance in connection with malaria is dependent on a retino choroiditis (which may be perceptible only with the microscope) or on a hemorrhage in the ciliary region, even when the ophthalmoscope shows no abnormalities of the fundus. Nevertheless, for practical reasons, we will preserve the division of visual disturbances into those " sine materia" and those with evident changes. Still, we must add that the designation " sine materia" is to be taken cum grano salis, and applies only to the negative ophthalmoscopic finding in vivo.
In this category we have a series of functional disturbances of the eye which are usually of short duration and pass with the paroxysm, but which may progress even to amaurosis.
Many such cases have been described, though, we must add, the great majority of them without the ophthalmoscopic findings. According to L. Raynaud, in whose thesis the entire literature of visual disturbances in malaria has been reviewed, and whom we intend in part to follow, Moraud (1729) was the first to draw attention to this subject. Storch (1838) speaks of an amaurotic latent. Since then numerous observations have been made by Testelin, Leber, Landesberg, Sulzer, de Schweinitz, and others.
This may be unilateral or bilateral. Peunoff observed lateral hemianopsia preceding the paroxysms. De Schweini tz reported a case of temporal hemianopsia with malarial parasites in the blood which was cured by quinin.
Dyschromatopsia has been less frequently observed (Peunoff, de Schweinitz, L. Raynaud).
Hemeralopia, amblyopia, and amaurosis are the most common disturbances. Segard met them frequently in Madagascar; Sulzer and Poncet mention them; and L. Raynaud gives several examples.
According to Sulzer's observations, the acuity of vision often manifests marked fluctuations in acute malaria , as well as in cachexia. The visual field is intact or slightly contracted concentrically. Central scotoma is rare. The visual disturbance is usually limited to the periphery of the retina, though the central parts are sometimes undersensitive. Contraction for colors is rare.
Ischemia followed by intermittent amblyopia was first described by M. Raynaud; again, by Mour sou (both times in connection with local asphyxia of the extremities). Ramorino and Decreu observed cases of ischemic intermittent amaurosis which were cured by quinin. The ischemia is characterized ophthalmoscopically by contraction of the vessels and pallor of the disk.
Hyperemia of the retina and of the disk was observed by Sulzer in 20 per cent, of the acute cases. Peunoff reported the same. We might say, in general, that hyperemia of the eye ground is a common occurrence during the acute attack.
Hemorrhages on the retina are not rare in pernicious cases. They are located, according to Poncet, usually in the ciliary, though sometimes in the macular, region, or even in the macula itself, and then commonly along the large vessels. Even hemorrhages into the disk are not very rare. Lopez y Veitia found the hemorrhages usually arranged radially to the papilla, along the vessels, and observed them increase during the paroxysms. After resorption they leave behind pale spots (MacKenzie) or disappear and leave no trace (Sulzer). Guarnieri found hemorrhages twice on microscopic examination of the eyeballs from ten persons who died of pernicious malaria .
Optic neuritis and neuroretinitis have been frequently reported. MacNamara and Jacobi were the first to direct attention to them. Among the later observers we may mention Sulzer and Poncet.
. Sulzer, who made his observations in Java, saw optic neuritis, especially in cachectics. As a characteristic subjective symptom, he described the already mentioned fluctuation in acuity of vision. This may rise from V ^ within a few weeks to , to return after a few days to the previous condition. The affection usually begins in one eye, but later goes over into the other. The field of vision is sometimes concentrically contracted. Hemeralopia and photophobia may occur. The papilla is swollen and dark red grayish; the veins are tortuous; the arteries contracted.
Atrophy of the optic nerve following malaria was first observed by Kohn, and later by Galezowski, Levrier, Bull, MacNamara, Sulzer, and others. Sulzer found that 80 per cent, of his cases of optic neuritis terminated in partial atrophy. The symptoms are diminution of the central acuity of vision, with scotoma and dyschromatopsia.
Poncet declares that the majority of affections of the fundus in malaria are to be considered as retinochoroiditis. Levrier and Peunoff observed choroiditis with clouding of the vitreous.
Hemorrhage into the vitreous the result of a single paroxysm was reported by Kries. Bull observed 17 cases of similar hemorrhages, the majority unilateral. Almost all the patients were over forty years old.
Seely described a serous infiltration of the vitreous in chronic malaria . Sulzer found this condition several times. In one case blindness was produced in a night in each eye at intervals of eight days. Eventually the patient became able to count fingers with one eye when they were held very close.
Disturbances of accommodation have been described in the form of paralysis by Bull, in the form of a spasm by Stellwag and Stilling.
Hypersecretion of tears has been frequently observed in latent supra orbital neuralgia, yet isolated cases have likewise been described in which it was present apart from the neuralgia, both during and before paroxysms.
Moursou saw a marine with paroxysms consisting of fever, vasomotor disturbances on the right half of the face, transient amblyopia, and hypersecretion of tears. Later this last symptom occurred alone without fever until cured by quinin. In regard to quinin amaurosis and the anatomic findings in cases of visual derangement, see the proper sections.