At first, lacrymation is usually marked, but, later, considerable dis charge appears, and superficial ulcers form at the Embus.
After several weeks the disease gradu ally subsides, usually leaving some cica trices in the lids to indicate its presence, although in other cases, after the ab sorption of the granulations, the mucous membrane may be quite smooth.
If the inflammation be but slight and not sufficient to absorb the granulations, the process may run into the chronic form.
Chronic granular conjunctivitis is usu ally primary-, but it may be due at times to the imperfect disappearance of the acnte granulations. The constant factor in this variety of trachoma is the tra choma-follicle, as it exists in all of the different degrees in which these condi tions are met with.
Tbe development of chronic granular conjunctivitis is often very insidious. -Usually, at first, marked lacrymation is present, although there is but little secre tion. If the cornea has become vascular, photophobia may be a most distressing symptom. The lids are swelled, and, upon their eversion, the characteristic granulations spring into view. They re semble sago-like prominences arranged in parallel rows, and are found in the superficial layers of the conjunctiva, es pecially in the fornix. Rarely a few smaller isolated granules will be seen on the bulbar conjunctiva. At first they are found in the lower cul-de-sac, but the upper cul-de-sac is soon affected and shows the greatest development of the follicles.
After a few weeks or months the gran ulations give rise to a more or less active vascular reaction, attended with swell ing of the papillm and a muco-purulent discharge. The papillm may becoine so large that they may obscure the granula tions. Occasionally the granulations be come absorbed, but in the majority of cases fresh eruptions of follicles present themselves during the period of regress ive inflammation and go through the same changes as their predecessors.
After a certain duration, grayish lines of fibrous tissue make their appearance, and the final stage of cicatrization be gins. As a result of this, dense scar-tis sue forms; this exerts traction upon the tarsus—already softened by the pre-exist ing disease--and produces the deform ities of the lids so characteristic of the affection.
Complications.—The corneal compli cation may take the form of pannus or of ulceration.
Pannus consists in the formation of a vascular tissue of neoformation on the cornea, which begins at the limbus and invades the centre. At the location of
the pannus the surface of the cornea is uneven and roughened, and there is a superficial gray and transparent haze, which is infiltrated by numerous vessels; these originate from the blood-vessels of the conjunctiva. The pannus usually be gins in the upper part of the cornea and frequently stops below, in a sharp, straight, horizontal border-line. Later, it may develop at other parts of the limbus; so that the entire cornea may become covered. Vision is affected as soon as the pannus reaches the pupil, which, if the cornea be entirely covered, may be reduced to light-perception.
When ulceration occurs, it is either at the edge of the pannus or upon a portion of the cornea which had hitherto been uninvolved. It usually occasions great photophobia and lacrymation.
The hypertrophy of the conjunctiva increases until the diseased process has run its course, when it begins to shrink, and is replaced by cicatricial tissue, with all its attendant evil consequences to the normal contour and function of the lids. The degree of cicatrization depends upon the severity of the early stages of the disease.
The beginning of the scar-formation shows itself in the tarsal conjunctiva, narrow, whitish lines permeating the lat ter. These lines become more numerous and form a fine net-work, which gradu ally spreads; the conjunctiva included within the meshes becomes attenuated, until quite smooth and white.
The hypertrophied conjunctiva in the fornix gradually shrinks, becoming shorter, and the folds of the conjunctiva in that location disappear. This is known as symblepharon posterior. In ex treme cases the cul-de-sacs arc reduced to shallow fissures between the lid and the globe. The lids become distorted, through the cicatricial changes in the cornea and tarsus, the latter participat ing in the inflammation, as well as the conjunctiva. It becomes much hyper trophied, especially along its lower mar gin, where the conjunctival vessels per forate it. It is especially in this position that the shrinking of the conjunctiva, which follows later, makes itself most felt, and is the main factor in the pro duction of the bow-like distortion of the lids, produced by trachoma. The cilia no longer occupy their normal position, but become displaced, and cause great irritation by being brought in contact with the cornea. This irritation is further augmented if the shrinkage of the tarsus continues, and entropion is produced.