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whom the iris was reduced to a narrow band, was quite motionless, and presented at its lower portion a serrated appearance from laceration. The case affords a good example of what generally happens under such circumstances--namely, a slow and incomplete recovery. (p. 171.)
From the practice of Mr. St. John Edwards, our author quotes the following case of fracture of the orbit and effusion of blood on the brain, from a blow on the eye:
"An unfortunate girl received a blow on the left eye, which blackened it; eleven days afterwards she died, and on post-mortem examination from five to six ounces of blood were found in the left arachnoid cavity, partly fluid, partly coagulated; the latter portion contained in its centre a fibrinous clot about the size of a small nut. The fluid portion of the blood was found to extend downwards to the base of the brain. The membranes were deeply stained with blood, as also the substance of the convolutions. The small wing of the sphenoid bone on the left side was found disarticulated and displaced backwards and upwards, exactly in a position to have wounded the middle cerebral artery in the fissure of Sylvius. Mr. Edwards was of opinion that the blow on the eye displaced the bone, which in its turn gave rise to the hæmorrhage by rupturing some vessel
, but that it temporarily plugged the vessel, and ultimately failing to do this, rapid extravasation of blood and death ensued.” (p. 177.)
The following cases of detachment of the retina, the one in consequence of a blow eye
and the other of a fall, are interesting: A countryman, aged twenty-six, received accidentally a violent blow over the right eyebrow from a flail
. He fell stunned, and was unconscious for some minutes. He then became sick, and discovered that he had lost the sight of his right eye. A week after the injury the brow still bore marks of the blow, the pupil was dilated and motionless, and the only sight was perception of shadows of objects when the image was thrown on the temporal portion of the retina. The ophthalmoscope revealed detachment of the retina over a space about two lines in diameter, behind which was a coagulum of blood, of a deep reddish brown. Where detached, the retina was slightly opaque, and had a generally congested and unhealthy aspect.
A man, aged forty-five, of robust constitution, in running violently, fell, and received a severe shock. About three weeks afterwards, on accidentally covering the right eye, he perceived to his astonishment that he could not see with the left. Examined about four months after the accident by Dr. Williams, he stated that he had never experienced the slightest pain or uneasiness in the eye. Of objects placed before him, or to his right side, he had not the faintest perception, but recognised, although very imperfectly, large bodies placed towards his left side. The pupil was dilated and immovable.
Examined with the ophthalmoscope, the refracting media appeared perfectly transparent, and the retina presented no abnormal vascularity; but it was easy to recognise that this membrane, to a large extent, and all round the entrance of the optic nerve, was elevated by a liquid, and had a trembling movement during the oscillations of the eye. During these movements those deep folds which the membrane ordinarily forms in dropsy of the retina, were not discernible; the folds were superficial and the undulations quite limited. These phenomena, taken in connexion with the pearly colour which the elevated membrane presented, could be explained only by supposing that the retina was raised by a turbid liquid, similar to what is often observed in pericarditis and other serous inflammations.
Mr. Cooper mentions that he had seen several [instances of cysts within the eye, arising without any well-ascertained cause; but three which fell under his notice were clearly traceable to injury.
“ These cysts,” he says, " as they ordinarily present themselves, appear to consist in the morbid formation of fluids between the iris and the uvea; but in some cases the seat of origin seems to be rather the ciliary margin than the posterior surface of the iris. In one of the cases,
the growth took place behind the iris, and gradually pushed its way through the pupil. The irritation caused by these cysts is great, and is mainly the result of their being enclosed within the unyielding tunics of the eye; as they increase and require more space, painful tension is excited.” (p. 186.)
“There is a tendency on the part of these cysts to refill if they are merely punctured, and
therefore I prefer lacerating the membrane with a broad needle; when punctured the fluid jets out, and the delicate membrane, which has been kept on the stretch, collapses. If this treatment does not succeed, and the pouch is large, it may be drawn out of the eye with canula-forceps, and a portion snipped off. This will effectually cure it." (p. 191.)
The following remarks are illustrative of a subject which has hitherto scarcely attracted notice-namely, posterior rupture of the eye.
“Rupture of the eye posteriorly, that is, behind the point of reflection of the conjunctiva, is a rare accident; and as the true character of the injury can only be ascertained by excision of the eye, doubtless cases in which it has taken place have escaped observation in the absence of the performance of that operation. It is the result of the sudden and violent blow inflicted full on the eye, and is attended with the sensation of the globe bursting; the eye fills with blood, and pain of the most distressing character racks the patient for many weeks, not a gleam of light being bearable; for though the injured eye is absolutely blind, the other is exquisitely sensitive to light. The symptoms subside by slow degrees, and atrophy of the eye takes place, varying in degree according to the extent to which the coagului within the eye is absorbed : for it must be borne in inind that this coagulu'n does not always disappear. I have met with a case in which the colouring particles were absorbed, but the fibrin remained in a firm mass.” (p. 197.) In illustration, Mr. Cooper gives a case which occurred in the practice of Mr. Bow
An elderly gentleman was struck full on the left eye by the door of a brougham suddenly thrown open. The agony was intense, but sight was not immediately extinguished, though after a few hours it became so. The anterior chamber was so full of blood that no part of the iris was visible, and the conjunctiva was chemosed. The accident. had occurred a month prior to Mr. Cooper's seeing the patient, during the whole of which time his sufferings had been intense. He could not bear a glearn of light. When the right eye was completely covered the left could be opened, but it was absolutely blind. The pupil
, of a dull reddish brown colour, appeared as if enormously dilated, and the iris reduced to a mere strip. There did not appear to be blood in the anterior chamber, but the back of the eye seemed full of it. The conjunctiva and sclerotica were acutely inflamed.
During the operation of removing the eye by Mr. Bowman, it was found that the sclerotica had been ruptured in the posterior part, and that a large coagulum lay partly without and partly within the eye. The vitreous humour had escaped at the time of the accident. The aspect of the anterior chamber had been deceptive, for though it had appeared free from blood, it was found filled with coagulum, behind which lay the iris, with the pupil of natural size, the apparent strip of iris being really the small portion visible beyond the margin of the coagulum. (Ibid.)
The facts of this case, as stated by our author, seem in some measure at variance with one another. The sight was not extinguished for some hours after the accident, and yet the vitreous humour had escaped through a posterior rupture of the eyeball, Either the patient must have been mistaken in supposing that he saw for some hours after the accident, or the rupture of the eyeball must have happened during the operation of extirpation.
The subject of dislocated lens is fully considered by the author. (pp. 200–220.)
When an opaque lens lies in the anterior chamber, it can only be regarded in the light of a foreign body, and ought to be removed under chloroform. In such a case, the moinent that the section of the cornea is made, the lens is api to sink back either entire or divided by the knife, through the pupil into the vitreous humour.
In a case related by Mr. Cooper (p. 206), one portion of the lens retreated through the pupil as the other was extracted. The best plan for preventing such an accident, is to begin the operation by passing a curved needle through the sclerotic, and fixing it in the dislocated lens ; then, to open the cornea, and with the needle to push the lens out of the eye. In determining the question which sometimes arises after injuries of the eye, whether
, the crystalline is in its natural situation in the eye, or in the eye at all, Mr. Cooper bas recourse to the catoptrical test ; as, if the lens is absent from behind the pupil, neither the inverted nor the deep-erect image is visible, but only the image formed by the cornea. Opportunity is here taken by Mr. Cooper to state, that the catoptrical test, as a means of detecting the existence of cataract, has been superseded by the ophthalmoscope, which certainly is not the fact. In many cases of incipient cataract
, the fundus oculi appears under the ophthalmoscope with almost no change of colour, while the haziness of the lens is so slight as to escape detection, especially if a strong and concentrated light is used; but the lighted taper, passed in front of the eye, by showing the changed condition of the the two deep images, instantly reveals the true state of the lens. We regard the catoptrical test as a simple and elegant means of diagnosis, which no one who has studied it with sufficient care, and comprehended its value, will think of abandoning.
The ophthalmoscope, again, is of great use in determining the amount and situation of extravasations of blood in the vitreous chamber, and of injuries of the retina.
The right eye of a farmer having been struck with a hollow wooden pear, thrown in sport, Mr. Dixon discovered with the ophthalmoscope, what he considered to be a rent in the retina, and a considerable coagulum of blood, which lay against that membrane. The case was subsequently examined by Mr. Cooper in consultation with Mr. Dixon.
“ The pupil was slightly dilated and motionless; nothing abnormal visible beyond this ; objects were seen by the patient indistinctly, and a black patch obscured the central portion; pica type was read with difficulty, each word requiring to be separately made out.
“The ophthalmoscope showed the seat of the rent in the retina as an opaque, irregular line, nearly in the axis of vision, and there were many small spots around this, evidently the remains of the coagulum of blood wbich had not been entirely absorbed.
“In our report we were enabled to state with confidence that, though Mr. J. might retain a certain amount of sight in the injured organ, we were of opinion that it would never be restored to its former perfection." (p. 234.)
The patient in this case sought compensation for the injury. He claimed 20001., but the referees awarded 7001., which, says Mr. Cooper, was accepted with very ill grace. . (p. 318). We think the case should have been watched for a considerable longer space of time before any legal or medical decision was given. It does not seem at all probable that, with a rent of the retina nearly in the axis of vision, the patient could have read pica type or any type. Might not what seemed a rent have been merely a sireak of blood ?
A blow on the eye is apt to produce effusion of blood between the sclerotic and choroid, between the choroid and retina, or within the vitreous humour. In all these cases vision is likely to be materially injured, if not destroyed.
“When a vessel,” says Mr. Cooper, “has given way between the retina and choroid, there will be seen a deep-red projection in the fundus of the eye, formed by the congulum over which the retina is stretched. In some instances the retinal vessels are distinctly visible coursing over the surface; after a time the retina may give way, and the blood then comes into contact with the vitreous humour, in which it may remain as a coagulum, or diffuse itself in the form of flakes.” (p. 235.)
We cannot deny the possibility of such a rupture of the retina happening as is here mentioned; but we do not recollect any evidence to show that such an event has actually followed any considerable time after the receipt of the injury.
Mr. Cooper remarks that
“Very serious intra-ocular hæmorrhage may arise after operations on the eye, especially extraction of cataract. It is one of the rarest and most disastrous complications that can present itself, utterly defeating the object of the operation and entailing much suffering on the patient. (p. 245.)
“A sudden and most acute pain darts from the eye back into the brain, and is followed by a sensation of tearing or dragging the eye from the socket. If the vessel gives way during or immediately after extraction, the vitreous humour will escape, and be followed by a flow of blood; but if some resistance is offered by union of the wound, the hyaloid becomes filled with blood, and the vitreous is lost sight of. The agonising pain soon involves the brow and side of the head, and the eye-lid is so exquisitely sensitive that it cannot bear the slightest touch.
"The first burst of pain is followed by faintness and nausea, often amounting to sickness, wbich nausea may continue many hours. The retching, however, does not prevent the stomach retaining small quantities of sustenance, and is best combated by soda water, and by effervescing draughts containing dilute hydrocyanic acid ; also by swallowing ice, either in lumps or as lemon ice. Cold jelly and cold beef tea are also grateful.
“When the wound is sufficiently united to offer resistance to the immediate escape of the contents of the eyeball, the hyaloid becomes filled with blood; and when the wound is burst open it gradually protrudes through the corneal section, and then between the lids, as a pouch filled with blood. The retention of this increasing the suffering, it should be snipped off.
" As the eyeball becomes distended with blood, the flap is widely opened, the upper lid thrust forward, and more or less edema arises, commencing at the inner corner.
“ The blood is usually venous, oozing from the eye and trickling down the cheek; there is every reason to believe that it is caused by disease of the choroidal vessels, and their morbid condition prevents their ready contraction, nor probably does the bleeding cease till they feel the influence of the pressure caused by the coagulated blood within the eye.” (p. 246 )
"Tbe careful examination of four eyes in the museum at Moorfields is conclusive to iny mind as to the seat of hæmorrhage. In one case the eye was excised for intra-ocular hæmorrhage after extraction, being the second case in which excision was performed there for that occurrence. Two eyes were excised from one individnal; in each Gräfe's operation had been performed for acute glaucoma; in each hæmorrhage took place, and they were removed. In the fourth case a staphylomatous eye was ruptured by injury.
“In all these preparations there is most distinctly visibly the coagulum of blood lying between the choroid and sclerotica, pushing the choroid and retina inwards, or inwards and forwards, according to the magnitude of the clot. In not one did the bleeding take place from the inner surface, but in all clearly from the external surface of the choroid, probably from the vasa vorticosa. A precisely similar condition existed in another eye excised for hæmorrhage after extraction, the description of which is in the ninth volume of the Transactions of the Pathological Society. I am therefore of opinion, that intra-ocular hæmorrhage after extraction is due to a diseased condition of the choroidal vessels, that it does not arise from rupture of the central artery of the retina, and that it occurs irrespective of loss of the vitreous humour, though the sudden withdrawal of the support afforded to the weakened vessels by that body may be a powerful predisposing cause." (p. 248.)
Three cases of hæmorrhage after extraction, which occurred in his practice, are related by Mr. Cooper. They are extremely instructive, and we only regret that our space does not allow of our quoting them at large.
Considering the very diseased state of the choroid in glaucoma, whether acute or chronic, we suspect that intra-ocular hæmorrhage must be a not unfrequent attendant on the operation of opening the cornea and snipping out a portion of the iris in cases of that disease. In addition to the instance referred to by Mr. Cooper, in which both eyes of a glaucomatous patient required to be extirpated in consequence of intra-ocular hæmorrhage after iridectomy, we observe it noticed in the number for January, 1859, of the Ophthalmic Hospital Reports, p. 299, that
“One glaucomatous globe was excised on account of the severe pain which followed the excision of a portion of iris (some vitreous had in this case been lost); portions of the choroid near the entrance of the optic nerve were displaced inwards by blood, which bad escaped from the outer choroidal surface, between the sclerotic and the choroid."
We would venture to suggest, if intra-ocular hæmorrhage is a common result of the operation of cutting up the living eye in glaucoma, that instead of assuring the patient that the operation is to restore sight, and adopting a proceeding which causes great suffering—so much so as to require excision of the eye for its relief-it might be better to remove the eye first, and to dissect it afterwards.*
* That relief to pain, and even preservation of sight, have followed iridectomy in some cases of glaucoma, does not admit of dispute. That excision of a portion of the iris, however, has any share in producing the benefical effects, is not proven : on the contrary, the presumption is, that, as in the following instance, the benefit is owing to the preliminary part of the operation--namely, the opening of the cornea, and evacuation of the aqueous humour :
"A man, aged fifty, of a lax, bloated appearance, otherwise of sound constitution, came under my care," says a celebrated operator, “about three months ago, on account of inflammation of his right eye, which had troubled him for eight days. I found the eye watering much, intolerant of light, the conjunctiva red and chemosed, the great ring of “ There is this curious fact,” continues our author, “ that so far as I am aware, sympathetic inflammation is not a consequence of the operations for cataract or artificial pupil, though extensive wounds are thereby inflicted on the cornea and iris, and in many cases the iris is involved in the cicatrix. Again, gun-shot wounds, though generally destructive to the eye, comparatively seldom excite sympathetic inflammation.” (Ibid.) the iris of a dull tarnished hue, the pupil fixed, dilated, and very turbid, and the power of vision so much impaired that the patient discerned only the movement of the hand, but could not count the fingers. He complained of a variety of subjective luminous sensations, and of violent pain in the right brow, temple, and side of the nose. I gave & very unfavourable prognosis, as the disease bore so undeniably the aspect of severe acute glaucoma. The patient was placed in a dark room, an energetic antiphlogistic and derivative treatment adopted, and a powerful opiate given in the evening. The inflammation was thereby considerably reduced, and the pain most completely removed: but the sight was improved only so far that the patient could slowly count the fingers at the distance of some feet, while the field of view was extremely limited. The pupil continued very obscure, depending, as is common in acute glaucoma, on a diffuse muddiness of the aqueous humour, and a deposit over the posterior surface of the cornea.
The following is an example of artificial ophthalmia coming under Mr. Cooper's observation :
“ An inmate of an orphan school was placed under my care at St. Mary's Hospital, by one of the governors, who took an interest in her forlorn condition. She was suffering apparently from chronic inflammation of the right eye, with slight haziness of the cornea. Week after week elapsed without amendment, notwithstanding a variety of treatment, and suspecting that there must be some cause for this, I took the girl into the hospital, and desired that sho should be watched. All I could learn was, that although always complaining of her eye to me, she never at any other time seemed annoyed by it. This convinced me that she in some way irritated the eye, but she was not detected, and after a month she was re-transferred to the out-patients' department, the eye remaining much the same.
"A few days after this, I met the girl a short distance from the hospital, on her way to it to appear before me. I stopped her, and without speaking, drew down the lower lid of the affected eye. The mystery was at once cleared up! A chip of wood had been cunningly placed between the lid and the eye, and was of course always reinoved when the eye was to be looked at. The chip was quite sodden with mucus, having evidently served this purpose for a long time.” (p. 291.)
It is a question of great interest, what are the tissues which, being injured in the one eye, are likely by sympathy to give rise to inflammation in the other. It is thought that sympathetic ophthalmitis is most apt to be excited if the wound has produced a protrusion of the iris, and such a cicatrix as keeps the remainder of the iris perpetually on the stretch, and that it is especially liable to occur if the retina has been divided or lacerated.” (p. 301.) In addition to what is here stated, we believe that it should be mentioned that such injuries as implicate the annulus albidus of the choroid, or in other words, the choroid muscle and the ciliary nerves, are more apt than others to be followed by sympathetic ophthalmitis. The presence, also, of fragments of iron, percussion-caps, and the like, within the injured eye, is a cause which should be particularly noticed, as apt to give rise to disease in the opposite eye.
“In a disease like this, which almost always mocks the influence of treatment, it is an imperative duty to make trial of some new remedy. No doubt we frequently see the symptoms of acute glaucoma subside, and after the use of antiphlogistics and mercurials, and especially after large doses of opium, an improved state of vision ensue: yet the hopes based thereon give way on a more extended experience, inasmuch as either the inflammatory attacks are repeated, leaving each time a more contracted field of view, or a continued loss of sight (with centripetal diminution of the field of view), gradually takes place, without any new attack of inflammation. Sufficient and sad experience of these results deterinined me to strike into another plan of cure for the above patient. As the amaurcsis which arises in the course of acute glaucoma is in a great measure proportionate to the increase of the internal pressure, denoted by hardness of the bulb, anesthesia of the cornea, paralysis of the iris, &c., although yet deeper changes, 1probably in the bloodvessels, forin the original cause, I determined powerfully to bring into play the means of dimiinishing pressure. After having with this view employed atropine without effect, I proceeded to paracentesis of the anterior chamber. Immediately after the first evacuation of the aqueous humour, the iris and pupil appeared much clearer, so that proof was furnished how far the diffuse muddiness of the aqueous humour had contributed to the dull appearance oi the eye. A corresponding improvement in sight also instantly took place, so that the patient could count the fingers at the distance of seven, in place of four feet. This evidently arose from the
removal of the turbid aqueous humour, which had disturbed vision by its absorption and dispersion of the light. The chief effect of the paracentesis consisted, however, not in the immediate, but in the gradual improvement which was observed in the course of the next day, so that the patient was able to make out large type ; this being plainly attributable to some change in the internal circulation of the eye. Some days later, as the aqueous humour aguin appeared somewhat turbid, the paracentesis was repeated, and this even a third time. Although the patient has now a dilated and nearly motionless pupil, and the iris has changed colour, he congratulates himself on possessing very good sight, so that, with convex glasses suited to his presbyopia, he reads the print No. 8 of Jäger's book, and hesitates only at the most difficult words of No. 1. Besides, the field of view is laterally completely unimpeded—that is, the extent and sharpness of excentric vision is normal, a circumstance which, since I have employed exact and appropriate means of measurement, I have never before observed in any case of glaucoma which had run its course,
Such is the important testimony of Dr. Von Gräfe ('Archiv für Ophthalmologie,' Erster Band, Abtheilung ii. p. 302, Berlin, 1855), in favour, not of any new treatment for glaucoma, as he seems to suppose, but of one long ago advised and found useful in that disease, and for which it is to be hoped that iridectomy will speedily be abandoned.