WOUNDS OF THE EYE, AND THEIR TREATMENT.”

BY A. H. EDWARDS, M. D.

I could think of no subject that would be of more interest to the general practitioner than wounds of the eye and their treatment. The subject is large, and one too upon which much might be written. I shall treat the topic, however, in a somewhat superficial manner, presenting it in as practical a way as possible, consistent with the amount of time that I propose to consume. I shall make no attempt at originality of thought or go minutely into the technique of diagnosis or treatment, and presume that you are familiar with the anatomy and physiology of the eye and its appendages, the lids.

A wound, as we shall here consider it, consists of a solution of continuity of the eye or its appendages, produced either directly or indirectly by sudden mechanical forces or by the destructive properties of some chemical agent, as acids or alkalies, generally the latter in the form of lime, either slacked or unslacked. For convenience of description we may divide wounds of the eye, as in other parts of the body, into incised, punctured, lacerated, and contused. Another classification would be into aseptic and septic. So, likewise, we may have a simple, compound, or complicated wound: simple when the agent producing the wound and any other foreign substance carried by it into the rent is removed, and complicated when any foreign body, whether the missile inflicting the wound or material carried by it, remains in the injured member. A compound wound, we may say, is one in which two or more of the entire parts of the eye sustain a simultaneous injury; thus we may have a punctured wound of the cornea with an escape of aqueous humor and a lacerated and prolapsed condition of the iris. Indeed, compound wounds are more frequently met with than those of any other variety. Our prognosis will depend largely upon the seat of injury, and upon its being simple or complicated. A simple wound, or

complicated one that is readily converted into a simple one, may often offer a favorable prognosis, though there be considerable laceration of tissue, provided the injury be not in the ciliary region. That part of the eyeball comprising a zone extending from the sclero-corneal junction in front, posteriorly six millimeters, and known as the ciliary region, has been very properly called by Nettleship the zone of dan

Read before the Paducah Medical and Surgical Society, March 9, 1898.

ger, owing to the fact that wounds in this region are most apt to set up a severe inflammation, resulting in most cases in total destruction of the eye, and a sympathetic involvement with its fellow of the opposite side as well. This is due to the anatomical fact that in this zone of danger is situated the ciliary nerves as well as the attachment of the iris.

Those fundamental principles laid down for treatment of wounds in other parts of the body hold good here: (1) Arrest the hemorrhage, this will rarely be found troublesome; (2) subdue any existing shock; (3) cleanse the wound of every vestage of foreign matter; (4) render the wound absolutely aseptic by thorough irrigation with an antiseptic solution of corrosive sublimate-1 to 10,000 parts; (5) coaptation of the severed parts, by sutures if necessary; (6) antiseptic dressing, and (7) position and rest, the latter accomplish with atropia—two to five grains to water one ounce-and light pressure bandage to control the movements of the lids.

We shall now speak of wounds of individual parts of the eye. Contused wounds of the eye, of which an ordinary black eye is a familiar type, are caused by blunt instruments, as for instance the closed fist of a combatant, and consist of extravasated blood (ecchymosis) from subcutaneous hemorrhage and infiltration of serum (edema). If seen early, apply cold for several hours to lessen the effusion; after this, warm applications, evaporating lotions, such as lead washes or sulphate of zinc, three grains to one ounce of water. Absorption of the effused material will usually take place in from seven to fourteen days, leaving the eye physically and functionally unimpaired.

Incised wounds of the lids require careful coaptation of the divided tissues, more particularly if the margin is involved. Black silk sutures are indicated, and the first suture should be at the lid margin. If not seen till twenty-four hours or more after the wound is produced, the edges must be pared so as to get healing by first intention. Wounds. of the conjunctiva alone are generally caused by some corroding agent, as acids or alkalies, and offer a favorable or unfavorable prognosis, depending directly on the extent of cornea involvement. If seen in time, wash out the offending agent, and, if that be an acid or alkaline substance, use at once an application that will neutralize or render it. insoluble, after which it may be removed as a foreign body. Atropinize the iris, subdue the inflammation with the cold applications, and keep a soothing, oily substance applied until the sloughing part is exfoliated,

after which use an antiseptic lotion of iodoform, grains ten to petroleum one dram. If both the occular and palpebral conjunctiva are involved, there is imminent danger of the two raw surfaces becoming united by the resulting cicatrix binding the lid to the eyeball, producing what is known as symblepharon. To prevent this condition of things the lids must be repeatedly separated from the ball and an antiseptic gauze kept interposed till healing is complete.

Superficial wounds of the cornea are among the most frequent of accidents, and are caused by the deposition in its structure of small pieces of steel, emery, grains of sand, cinders from a railroad locomotive, etc. The symptoms are photophobia, lachrymation, and particularly severe pain, with more or less irritation of the iris. With a four-per-cent solution of cocaine applied to the parts and under focal illumination lift out the offending body with a corneal spud. In more severe cases, where the ciliary body or iris is involved, use atropia to paralyze the accommodation and as it were put the iris in a splint. The prognosis in this class of wounds is good. Incised, lacerated, or punctured wounds of the cornea are more baneful in their results. There is usually an escape of aqueous followed by a prolapse of the iris, its fibers being entangled in the lips of the wound. If only the corneal tissue is impaired with a prolapsed iris, we may preserve the integrity of the parts, provided we see it early and the wound does not become infected.

First, we assure ourselves that no foreign body remains in the eye. Second, we endeavor to disengage the iris from its corneal incarceration by careful manipulation with the spatula, assisted by an aqueous solution of atropia-four grains to the ounce-if the rent be near the pupilary opening; and with eserine-one grain to the ounce-if it be near its attachment. If we fail in this, as we most likely will do unless the eye be seen very soon after the accident, the portion prolapsed is to be grasped with a pair of delicate iris forceps, gently drawn out, and as much of it as possible clipped off with the scissors; after which the stump may be disengaged by the assistance of a mydriatic or myotic, as the case demands. The conjunctival sac is then flushed with an antiseptic solution, the wound covered with finely pulverized iodoform, the lids gently closed, and a light pressure bandage applied. If the lens or its capsule be punctured, although the iris remains intact, and the cornea sustains only slight injury, we may expect traumatic cataract. If the agent inflicting the injury remains in the eye, our first effort

should be directed to its removal; for without this the destruction of the eye is almost certain to follow, and a large per cent are lost even with such removal. If the offending agent be located in the anterior chamber, the iris or lens, we remove it through the original opening with forceps, or, in the case of steel, with the electro-magnet, if possible, or, failing in this, we may make a suitable opening for the purpose. It must not be forgotten that wounds of the cornea involving its integrity beyond Bowman's membrane will be followed by a permanent opacity, more or less dense, and an impairment of the eye's function by a diffusion of rays of light directly in proportion to their density and situation in the pupilary area of the field of vision. Wounds of the sclerotic, while less frequent than those of the cornea, are not rare. If there is a prolapse of vitreous, it is to be clipped off with scissors, the opening in the sclerotic closed by fine silk sutures, the eye dressed antiseptically, and favorable or unfavorable results expected, according to the situation and extent of tissue involved. If the lesion be in the zone of danger and extend to and include the ciliary body, the eye will almost certainly be lost. It is hardly necessary to say that in all manipulations of the wounded eye, either instrumental or otherwise, the most scrupulous antiseptic precautions should be observed. As to those cases in which enucleation is indicated, no definite rule can be formulated, since the intelligence, occupation, and situation of the patient by the surgeon must be taken into consideration. Of course the object of excision is to remove the peril of sympathetic inflammation. It is fortunate that sympathetic irritation, which is to be clearly differentiated from sympathetic inflammation, usually precedes the latter and serves as a signal for immediate. enucleation.

A wound involving the integrity of the zone of danger or one in which a foreign body remains in the eye, is the most prolific cause of sympathetic disturbance. The opinion of the best authorities indorses the idea that sympathetic troubles are of bacterial origin, the microorganisms traveling by continuity of surface beneath the optic nerve, sheathed by way of the optic chasm from the offending eye to the sympathizing member. The time at which sympathetic inflammation usually begins is from four to eight weeks after the traumatism, no case being on record as having occurred sooner than two weeks; while one case has been seen sixty years afterward. Sympathetic irritation is purely functional, and has for its symptoms lachrymation, neuralgic

pains in the supraorbital region, tenderness on pressure over the ciliary region, photophobia and impaired accommodation, the latter two being the more constant.

When this condition of things exists, immediate enucleation of the offending eye is the correct thing to do, and the surgeon who fails to appreciate the situation and advises his patient accordingly, falls far short of accomplishing his mission, inasmuch as a prompt removal of the source of irritation at this stage of the trouble will, in most cases, bring about a speedy subsidence of all symptoms and a restoration of the normal vision. If, however, from any cause enucleation has been deferred till sympathetic irritation has given place to well-marked symptoms of inflammation, it should by no means be performed, provided any degree of vision remain in the offending eye it will most likely prove to be the most useful of the two; hence, by enucleation of the offending eye before sympathetic trouble is precipitated in its fellow is the only successful treatment.

Therapeutically we use atropia, hot fomentations, local blood-letting by leeches to the temple, setons in chronic forms and confinement in a dark room; but nothing heretofore practiced has been of much avail in the treatment of a well-developed case of sympathetic ophthalmia. A safe working rule, with few exceptions, demands enucleation, (1) when the wound is of such a nature as to destroy sight completely; (2) when the wound is in the ciliary region, especially if the iris be prolapsed, rendering inflammation reasonably certain; (3) when judicious efforts have failed to remove a foreign body and there is an iritis, even if the vision be not entirely destroyed; and (4) when the offending eye is blind, to remove a source of irritation and thus render treatment of an existing sympathetic trouble more effectual. The prognosis of sympathetic inflammation is, hence, very grave, and the surgeon should not fail to so inform the patient or his friends, and if an attempt be made to save the offending eye, it should be done after a thorough understanding of the risk assumed as to sympathetic involvement.

PADUCAH, KY.