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Perforation of an ulcer peripherally situated, especially below, is followed by adhesion of the iris to the opening. The aqueous escapes, and, as the iris and the lens fall forward, the former becomes entangled in the perforation, and is fixed by inflammatory exudation. The adhesion is either on the posterior surface, or in the cicatrix, and the resulting dense white scar receives the name, adherent leucoma.

If the region of the scar is bulged forward because it is unable to resist the intraocular tension, anterior staphyloma results. Extensive sloughing of the corneal tissue, with total prolapse of the iris, matting together of the parts by exudation, and protrusion of the cicatrix, constitute a total anterior staphyloma.

Finally, perforation may be followed by inflammatory involvement of the ciliary body and choroid, and the rapid destruction of the eye through panophthalmitis, or a slower shrinking of the tissues, with atrophy of the bulb. Dense opacity occasionally appears in the cornea during convalescence, and may go on to ulceration, or clear up perfectly. It may arise with great suddenness, and, when it occurs in the lower half of the cornea, a deep indentation, owing to the pressure of the margin of the lid, is likely to occur.

The appearance of the conjunctiva differs materially in different cases. Its surface may be covered over, not merely with easily detached flakes of lymph, but with a gray, false membrane. More rarely, a deep infiltration develops, like that seen in diphtheritic conjunctivitis.

Restlessness, fever, and other constitutional disturbances are sometimes present, and synovitis of the knee and wrists may arise, of the same character as similar complications occurring in adults during gonorrhea.

Ophthalmia neonatorum does not always follow this course, because the term is made to include affections of the conjunctiva in the newborn, other than the types just described -- mild catarrhal ophthalmias, hyperemias, and that variety which, according to Noyes, presents the character of a granular, rather than of a purulent conjunctivitis, and which may continue for weeks without danger of corneal complication.

Some hyperemia of the conjunctiva, with a little yellowish discharge in the corners of the eye, and slight swelling of the lower lid, is common in babies for a few days after birth, and may be attributed either to uncleanliness, or to change of temperature.

Diagnosis. -- The onset and character of the disease, its symptoms and course, render a mistake in regard to its nature practically impossible. Close attention should be given to what at first appears to be a trivial inflammation in the eyes of a new-born child, because a virulent and destructive inflammation may follow with great rapidity.

Prognosis. -- This is always grave, the gravity increasing in direct proportion to the violence of the inflammation and the condition of the cornea. The attendants of newborn children should be impressed with the necessity of seeking capable medical advice at the very moment of the appearance of any conjunctival trouble. If, as only too frequently is the case, treatment has been neglected until extensive sloughing of the cornea has occurred, no form of medication can do more than relieve the violence of the inflammation, which, when it subsides, leaves the child with sight hopelessly marred, perhaps destroyed.

Prophylaxis. -- The present high standard of scientific midwifery includes such cautious vaginal antisepsis during labor, that the risk of contamination is distinctly less than in former times, but still some preventive method should be employed.

Crede's plan, commonly adopted, yields excellent results. This consists in dropping into the conjunctival sac one or two drops of a two per cent, solution of nitrate of silver, the lids having previously been wiped dry. Other materials recommended for the same purpose are aqua chlorini (Schmidt-Rimpler), and bichloride of mercury. The hands of the mother, nurse, and child should be searched for sources of infection, and, in addition to the usual antiseptic precautions during labor, if gonorrhea is known to exist in the mother, the child should be removed from the immediate surroundings of the lying-in woman.

Treatment. -- If the type is mild, the applications described under simple ophthalmia are indicated; if severe, three conditions demand attention: The inflammatory swelling of the lids, the state of the conjunctiva, and the corneal complications.

(1.) During the earlier stages, when the lids are tense and the secretion lacking in its later creamy character, in addition to absolute cleanliness, local application of cold is the most useful agent.

This should be applied in the following manner: Upon a block of ice, square compresses of patent lint are laid, which, in turn, are placed upon the swollen lids and as frequently changed as may be needful to keep up a uniform cold impression. This is far preferable to the use of small bladders containing crushed ice; indeed, the use of ice for infants is not advisable. The length of time occupied with these cold applications must vary according to the severity of the case. Sometimes they may be used almost continuously, and sometimes frequently for periods of half an hour at a time.