Injuries Of The Eye And Its Appendages

Injuries Of The Eye And Its Appendages
By ALVIN A. HUBBELL, M. D., PH. D.,
OF BUFFALO, N.Y.

THE eye may be injured in a great variety of degrees and ways by contact with overheated substances, as hot vapors, liquids, or solids; or with caustics or eseharotics, as acids, caustic alkalies, and lime, whereby the parts become burned or corroded; or by mechanical forces or bodies impinging upon it, whereby its tissues are contused, lacerated, abraded, cut, or penetrated.

Injuries of the Cornea and Conjunctiva from Heat and Chemicals. Heat and chemical substances affect the tissues of the eye similarly. The anterior portion of the eyeball is most exposed to these agencies, and is therefore more frequently injured by them, the palpebral conjunctiva suffering only when the injurious substance gets beneath the lids. Burning gases and hot water or oil cool quickly and seldom reach the surface under the lids. Their effects, therefore, are more superficial and less extended than those of hot or molten metals or of chemicals and lime.

When the injury is superficial a whitish film is formed which is soon thrown off, and the parts rapidly regain their epithelium and their normal transparency (Plate 4, Fig. 1.). When the injury affects the deeper tissues the eschar is thicker, and its elimination leaves a granulating surface, which on healing may contract or lead to adhesions if it is on the conjunctiva, or produce opacity if it is on the cornea. Should the whole thickness of the cornea be involved, a perforation will take place with all of its consequences.

Symptoms. Besides the appearances above noted, there are, immediately after the injury, severe burning pain, redness of the eyeball, and lachrymation. Later, active inflammation may take place, with increased redness, and even chemosis, of the conjunctiva and swelling of the lids. When a considerable surface of the conjunctiva is affected, the secretion becomes muco purulent, and sometimes purulent. Implication of the cornea causes much pain and impairment of vision.

Treatment. When the case is seen immediately and the injury is from an acid, it should be neutralized by the application to the affected area of a weak alkaline solution. For this purpose bicarbonate of soda or bicarbonate of potash (saleratus) may be used. The latter has the advantage of accessibility, as it may be found in almost every house. When the offending agent is lime, caustic soda, caustic potash, or other alkali, it may be neutralized by an acid largely diluted, and here vinegar, diluted, answers the purpose, and generally is also within easy reach.

After neutralizing the chemical and removing such foreign substances as may be present, the parts should be cleansed with some mild antiseptic, and iced cloths kept constantly applied over the eye till the burning pain has ceased. Frequent instillations of a cocain solution will contribute much toward the relief of the pain. The subsequent treatment is the same as that of conjunctivitis or of ulceration of the cornea from other causes.

In cases where opposing surfaces of the conjunctiva are denuded, but the retrotarsal fold is unaffected, adhesion, or Symblepbaron (Fig. 231), may be prevented by frequently drawing the lid away from the eyeball or by interposing some smooth, flat substance between the lid and ball. But when the denudation includes the retrotarsal fold, such efforts will be absolutely fruitless and may as well be withheld. Should the lesion of the ocular conjunctiva be limited in extent, it may be covered; either immediately after the injury or after the eschar has sloughed off, by drawing the surrounding conjunctiva over it with sutures introduced from side to side. Sometimes adhesions can thus be very much restricted or even prevented.

Mechanical Injuries of the Cornea without the Lodgement of Foreign Bodies. These injuries include scratches, contusions, superficial punctures, and erosions, and may be. inflicted in a multitude of ways.

Symptoms. Injury of the cornea is determined by inspection, aided by oblique illumination, and is shown by loss of epithelium and irregularity of the injured surface. The denuded area may be detected by coloring it with fluorescin (page 145). place, there will be present.

There is a scratching, pricking feeling in the eye at first, and afterward there may be severe pain. The eyeball becomes red, there is free lachrymation, and, with a lesion centrally situated on the cornea, vision is more or less impaired.

Prognosis. This depends on the part injured and the progress of the case. There is impairment of sight in proportion to the involvement of the center of the cornea and the distortion of it which the injury and cicatrization cause. Wounds of the cornea are extremely liable to infection, and are therefore prone to ulceration or suppuration.

Treatment. The eye should first be cocainized, and the injured parts gently but thoroughly cleansed with 1 :4000 solution of bichlorid of mercury care being exercised not to rub away or loosen the adjacent corneal epithelium. Atropin solution should then be instilled and a compress bandage applied.

The subsequent treatment consists in using some form of antisepsis, continuing the instillations of atropin, and keeping the eye covered. Should ulceration or suppuration take place, it is to be treated as elsewhere described (see page 315).

Mechanical Injuries of the Conjunctiva without the Lodgement of Foreign Bodies. The conjunctiva may be cut, lacerated, punctured, or contused in many ways and by many kinds of objects.

Symptoms. An effusion of blood (ecchymosis of the conjunctiva), sometimes only slight, underneath the conjunctiva at the site of the injury is one of the most constant symptoms. The ecchymosis usually spreads, and may even surround the cornea. A puncture or small cut is not always apparent, but when the wound is larger it is recognized by its roughened surface and reddened edges, and later by the whitish appearance of the parts denuded of conjunctiva. There is seldom any pain beyond a scratching feeling, as if a foreign body were beneath the lid, and iris inflammatory reaction is seldom marked.

Treatment. When the conjunctiva is cut or torn in such a manner as to gap or produce a flap, the eye should be cocainized and the wound closed by fine silk sutures. Insti Rations of boric acid solution afterward are usually all the treatment that is necessary. Should the ecchymosis, however, be large and disfiguring, its absorption may be hastened by bathing the closed eye with water as hot as can be borne for fifteen or twenty minutes at a sitting, repeated two or three times a day.

Injuries of the Eyeball from Contusion, Concussion, and Compression. A blow on the eye by some blunt substance, or striking the eye against some object, or a sudden compression of the eyeball by some peculiarly directed force, or a violent explosion near the eye, may result in a solution of continuity and contiguity of its tissues, without their being penetrated by the offending agent itself. Stich lesions are single or multiple, and consist in general contusions of the ball ; rupture of the intraocular blood vessels; rupture of the outer coat of the eye ; laceration of the iris ; displacement of the iris; laceration of the ciliarv body ; detachment of the choroid ; rupture of the choroid ; detachment of the retina ; rupture of the zontila; dislocation of the lens ; rupture of the capsule of the lens ; iridoplegia; cycloplegia; spasm of the circular fibers of the iris; spasm of the ciliary muscle ; anesthesia of the retina; " commotion " of the retina; and pigmentation of the retina.

Contusion of the Eyeball. A blow on the eye may bruise the tissues without causing any apparent laceration or other lesion.

Symptoms. There are redness and tenderness of the eyeball, and sometimes pain. Occasionally there is produced anesthesia of the retina, mydriasis, loss of accommodation, spasm of the sphincter of the iris, or spasm of the ciliary muscle, with the symptoms belonging to each.

Traumatic amblyopia, or amaurosis (Berlin) is said to exist when the vision becomes slightly and transiently impaired or entirely and permanently lost without visible anatomical change in the retina.

A similar condition has been described as traumatic anesthesia of the retina (Leber). This is shown by weakness, unsteadiness, and impairment of vision, with restriction of the visual field conditions which may continue for several weeks or months (see also page 414).

In mydriasis (iridoplegia) the pupil is usually widely dilated. The dilatation may disappear in a few days, but it is frequently permanent. While it exists vision is dazzled when exposed to ordinary daylight from the admission of too much light into the eve.

of the ciliary muscle (cycloplegia) is often associated with mydriasis, although it may exist alone. The patient cannot accommodate for near objects, while the vision for distance may not be affected.

Spasm of the iris and ciliary muscle is indicated by a contracted pupil and by apparent myopia.

Treatment. The eye should be given rest, cold applications should be used, pilocarpin or eserin should be instilled for mydriasis and loss of accommodation, and atropin for spasm. Retinal anesthesia has been treated by suggestion'' on the theory that it is hysterical in its nature.

Rupture of the Eyeball. Rupture of the outer coat of the eye is of rare occurrence, and is produced by extreme violence. Its location is scarcely ever in the cornea, but it is most frequent in the anterior part of the sclera. It is largely determined by the position of the eye at the time of the injury, which is usually upward; the direction of the blow, which is generally from* below or from Below and outward; and the comparative weakness of the sclera between the margin of the cornea and the ciliary region. It is found, therefore, in most cases from one to three millimeters behind the margin of the cornea in the upper or upper and inner part of the sclera. Sometimes it is in the upper and outer part, or directly inward or directly outward. It is seldom directly outward. The rupture usually spans one third to onehalf of the periphery of the cornea. Partial rupture may occur in which the inner fibers of the sclera are torn, while the outer ones are more or less stretched. Rupture of the eyeball occurs almost exclusively in adults (see Plate 4, Fig. H.).

Symptoms. A rupture of the eyeball is signalized by the following Symptoms : immediate loss of sight, which may or may not be regained afterward ; softness of the eyeball ; congestion and ecchymosis of the conjunctiva; and, when the conjunctiva is not torn or the rupture is not situated anterior to its circumcorneal attachment, the presence of a distinct elevation or "tumor" of the conjunctiva from the extrusion of more or less of the intraocular structures. The edges of the rupture are ragged, and the lens, iris, ciliarv body, choroid, retina, or vitreous humor may be protruding through it or entangled in it. Sometimes the iris or lens is entirely expelled from the eye or lodged underneath the conjunctiva. The other appearances are such as belong to rupture of blood vessels, laceration of the iris, rupture of the choroid, and other lesions.

There is usually very little if any pain at any time, unless, as sometimes happens, severe inflammation supervenes.

Prognosis. The prognosis is usually very unfavorable, although in exceptional cases useful vision has been known to return. The extensive lesions, the large amount of hemorrhage, the excessive loss of vitreous, and the inflammatory reaction are generally sufficient to produce loss of vision and shrinking of the eyeball. Should the wound unite imperfectly, scleral staphyloma may follows Incarceration of the iris or ciliary body in the wound or a laceration extending into the ciliary body may cause sympathetic ophthalmitis.

Treatment. When, because of very great injury of the intraocular structures, excessive hemorrhage into the vitreous chamber, or extreme collapse of the eyeball, there is no possible hope of recovery, time and suffering can be saved by enucleating or eviscerating the eye ai once. But when there is reason to believe that there is a possibility of the eye being saved with partial vision, the practitioner is justified in making an attempt to do so, at least for two or three weeks, during which time there is scarcely any danger of sympathetic inflammation. At the end of this time, if the symptoms promise well, the effort may be continued. But if not, further risk should not be taken, except under peculiar and pressing circumstances.

If it be decided to try to save the eye, it should be cocainized, and with strict antiseptic precautions the rupture should be closed. To this end the conjunctiva, if not already ruptured, should be opened (contrary to the old practice), and all extraneous substances carefully removed, both from the outside and from between the lips of the wound. Protruding iris, ciliary body, or other tissue should be withdrawn and excised or cautiously replaced, as incarceration would interfere with solid union or cause irritation in the future. Any loose shreds hanging from the edges of the wound should also be cut off. Having thus made the wound as clean and smooth as possible, a sufficient number of fine antiseptic sutures, either silk or catgut, should be introduced from within outward and at a depth sufficient to bold firmly, and its edges closely drawn together. After tying and cutting off the threads, the wound should be covered, if possible, by conjunctival flaps held in place by suitably adjusted sutures. Catgut sutures may be allowed to remain, but silk ones should be removed in two to four days.

Having closed the wound, a solution of atropin should be instilled, the eye bandaged, and the patient put to bed and kept quiet for several days. Cold applications are useful, especially if inflammatory reaction threatens. Other conditions and symptoms are to be treated as they arise and according to directions given elsewhere.

When a case is not seen until after the wound has united the practitioner is generally quite powerless. Prolapse of the iris may be reduced by the galvano cautery. Other lesions must be treated according to indications.

A rupture of the cornea is to be treated similarly to that of the sclera, except that it is not usually practicable to introduce sutures or to cover the wound with conjunctival flaps (see also page 569).

of Ocular Blood vessels. Contusion of the eveball may rupture blood vessels of the iris, causing effusion of blood into the anterior chamber hyphema or of the choroid or retina, causing effusion of blood into or beneath these membranes or into the vitreous humor hemophthalmia.

Symptoms. There is seldom any pain beyond that produced by the contusion. The presence of the blood usually obstructs the vision, either partially or totally. When the blood is in the anterior chamber it settles to the dependent portion, and its upper edge or surface is straight (see Plate 4, Fig. 11.). It is seen in its natural color or perhaps a little darkened. Blood in the vitreous humor appears with the ophthalmoscope as a dark object, and when large in quantity it may be seen, with the pupil dilated, by oblique illumination as a dark red reflection.

Prognosis. A hemorrhage into the anterior chamber of a previously healthy eye is absorbed in two to four days, but one into the vitreous humor requires weeks or months for absorption, and when it is of considerable size it often leaves permanent residues and opacities, and may even lead to disorganization of the vitreous humor and shrinking of the eyeball.

Treatment. The treatment is limited to covering the eye, giving it rest, and instilling a weak solution of atropin. In some cases it may be preferable to instil pilocarpin instead of atropin. Hot water or hot fomentations continuously applied over the eye for fifteen to twenty minutes two or three times a day hasten the absorption of the blood. The internal administration of iodid of sodium or similar alterative is useful.

Contusion injuries of the Iris; Lacerations or Ruptures of the Iris. Aside from hemorrhages, the most common lesions of the iris from blows or contusions are rents or lacerations. In extreme cases the iris may be torn entirely from its peripheral attachment (traumatic aniridia), and when the eyeball is ruptured it may be expelled from the eye or a segment of it may be torn away instead of the whole (traumatic coloboma). Partial detachment of the iris from its periphery at one or more points (iridodialysis) is the form of rent most frequently found. Radial lacerations rarely occur, and are usually at the pupillary border (rupture of sphincter).

Symptoms. Hemorrhage is usually present in the anterior chamber at first, and it may obscure the parts. But after its absorption inspection with or without oblique illumination will reveal a laceration or rent of the iris if one exists, or the absence of the iris if it has been expelled. When it has been entirely detached, but not expelled, it will be seen in the bottom of the anterior chamber as a rounded mass, dark in color at first, but soon changing to an ash gray. It rapidly shrinks to an inconspicuous size.

In a rent of the pupillary border, involving as it does the sphincter of the iris, the pupil is widely and permanently dilated (Fig. 232).

Traumatic coloboma in connection with rupture of the sclera should not be mistaken for retroflexion of the iris.

In iridodialysis the rent is easily discerned, unless very small and hidden by the opaque limbus cornea. The portion of the iris detached retracts toward the centre of the pupil, and the latter loses its circular form and becomes somewhat kidney shaped (Fig. 233). With the ophthalmoscope the fundusreflex can be seen through the new opening as well as through the pupil.

Treatment. Very little can be done to remedy most of these lesions. Dr. Eugene Smith ' of Detroit has suggested that iridodialysis be corrected by making a small incision at the corneo seleral junction at the place of the detachment, and by means of iris forceps catching the edge of the iris and drawing it into the incision. It is usually held in place by the compression of the lips of the wound ; but if this be not sufficient, it may be attached by a delicate suture to the neighboring conjunctiva. Before attempting this operation all irritation from the original injury must have subsided.

Displacements of the Iris: Retroftexion and Anteversion. retrocession and anteversion of the iris are very rare. In retroflexion a part, sometimes the whole, of the iris is thrown backward, so as to lie against the ciliary body. The pupillary portion alone may be thus displaced, or it may carry with it the whole width of the membrane. It occurs almost exclusively in cases where the lens has also become displaced. Only a part of the circumference of the iris is implicated in most cases, and this part becomes invisible, the appearance being much like that of an iridectomy. When the whole iris has thus receded the appearance is that of aniridia.

In anteversion a portion of the iris is torn from its periphery (iridodialysis), and the loosened segment is twisted upon itself or turnea over so that its posterior surface is directed forward. The exposure to view of the pigment surface of the iris and the partial or complete obstruction of the pupil, together with the traumatic opening of the iridodialysis, determine the existence of this double lesion.

displacements call for no treatment, unless the vision be interfered with in anteversion by the detached membrane lying across the pupil, when it may be excised by an iridectomy.

Contusion injuries of the Ciliary Body. These undoubtedly may' occur, but outside of such as accompany rupture of the sclera their existence is always difficult to ascertain and their diagnosis is doubtful.

Contusion injuries of the Choroid. These are hemorrhage, detachment, or rupture.

Hemorrhage may take place beneath the choroid, into its substance, or into the vitreous humor. In itself it obstructs the visual field, either as a whole or in sections, according to its extent and situation. When the hem is in or beneath the choroid it may be small or large, and appears with the ophthalmoscope as a bright red spot of irregular, oval, or circular form. The retinal vessels pass over it without interruption. In extravasations into the vitreous humor the conditions and appearances are those already described.

Detachment of the choroid is but the effect of a subchoroidal hemorrhage. It disappears with the absorption of the blood, and unless it is very small a long time will be required to accomplish this result. Spots of localized degeneration and atrophy of the choroid will be left with pigmentary deposits around them (see also page 357).

Rupture of the choroid is usually single and situated between the optic disk and macula ruled, and the retina is seldom involved. It is generally curved and runs vertically, its concavity being toward the optic disk. It varies in width from one third to one half the diameter of the optic disk, tapering toward its extremities, and in length from one to four diameters. Exceptionally, there may be more than one rupture, or it may be branched and its direction may be oblique or horizontal.

The rupture cannot be seen until the blood, which has generally been effused into the vitreous humor, has been absorbed. It is then shown by the ophthalmoscope as a more or less sharply defined rent, at first yellowish with red margins, and later white with pigmented margins, and with retinal vessels passing unbroken across it (consult Plate 3, Fig. 111.). Detachment of the retina sometimes follows cicatrization of a ruptured choroid.

In rupture of the choroid vision is at first much reduced or lost. After two or three weeks sight begins to return, but it is seldom fully regained. There is always left a scotoma corresponding to the rupture, and metamor is a common sequence (see also page 357).

Concussion injuries of the Retina. A blow on the eye may cause hemorrhage, rupture, detachment, so called "commotion," or pigmentation of the retina.

A retinal hemorrhage is easily recognized by its elongated, irregular shape, by the break of continuity of a retinal vessel, arid, if near the macula lutea, by a disturbance of vision and scotoma. The edges of the rent are ragged and the choroidal vessels are sometimes exposed. Whitish cicatricial lines, bordered with pigment, are seen later (Fig. 234).

“Commotio retina " is a term used to designate a peculiar effect characterized by edematous swelling and opacity of the retina, usually at the posterior part of the eye at a point opposite to that struck. It begins an hour or two after the injury in disseminated patches as grayish or dotted opacities. These gradually coalesce and become more dense, until there is one continuous, whitish, and even brilliantly white surface of ten to twelve optic disk diameters. This opacity is at its height in twenty four to twentysix hours, and usually disappears in two or three days. There may be retinal hemorrhages, and the retina may be ruptured or fissured, but its vessels are not bidden by the opacity.

The vision is much reduced or abolished at first. It improves for a short time rapidly, but afterward slowly. The central part of the field is that principally affected, and there seems to be no relation between the state of vision and the extent or depth of the opacity. The vision is further dis¬turbed by astigmatism caused by irregular spasm of the ciliary muscle and iris.

Detachment of the retina from a blow is not different in character and symptoms from that due to other causes (page 428).

Pigmentation of the retina is another result of contusion, and choroiditis, in all particulars resembling the exudative variety of this disease, may have the same origin (see also page 354).

Treatment. In all these lesions the eye should be shaded and given rest. Atropin should be instilled when there is evidence of spasm of the iris or ciliarv muscle. Detachment of the retina is to be treated like the non trau form of the disease (see page 430).

Contusion injuries of the Crystalline Lens. Contusion of the eyeball may cause rupture of the zonula, dislocation of the lens, rupture of the anterior or posterior capsule of the lens, with opacity, or there may be opacity of the lens without rupture of its capsule.

Rupture of the Zonula. This occurs usually in connection with dislocation of the lens. There is loss of accommodation and an increase of the refraction of the eye. The anterior chamber is sometimes deepened and the iris tremulous.

There is no remedy for this lesion.

Dislocation of the Lens. The lens may be dislocated in different directions and degrees. In rupture of the sclera it may be expelled or lodged beneath the conjunctiva. It may be tipped or turned on its equatorial plane, or thrown partly through the pupil and there held by the sphincter of the iris, or it may be completely displaced forward into the anterior chamber or backward into the vitreous humor. In all cases the zonula is ruptured and the lens sooner or later becomes opaque (Figs. 235 and 236).

Symptoms. In partial dislocations vision becomes greatly impaired by the irregular refraction of the margin or the obliquity of the lens, or by its opacity. When the lens is dislocated into the anterior chamber and remains transparent the refraction is increased and the vision is myopic. When it is completely displaced into the vitreous humor the refraction is diminished and the vision is that of an aphakic eye.

A transparent lens in any position when seen with the ophthalmoscope gives a reddish or yellowish reflex through its body, while its margins, if they can be seen, are dark or quite black. When in the anterior chamber these appearances are intensified, and it is seen as a pale, yellowish, or " palewine yellow" pellucid body with a brilliant reflection from near its edge of a golden luster. When the lens is opaque it is shown both by the ophthalmoscope and oblique illumination as a rounded, smooth, dark or gray body, sometimes becoming quite white. In the anterior chamber it generally causes much irritation, and sometimes severe inflammation, with increased tension and loss of vision. In the vitreous humor it causes a deepening of the anterior chamber and the iris becomes tremulous. Sometimes it is fixed in the bottom of the vitreous humor, and sometimes it moves about. It may remain in this position without doing harm for a long time ; but generally, sooner or later, it causes glaucoma, cyclitis, and other secondary diseases, and even sympathetic inflammation.

Treatment. A lens dislocated under the conjunctiva may be left to disintegrate and absorb, or it may be removed through an opening in the conjunctiva.

In a partial dislocation an iridectomy may be made when the margin of the lens lies in the axis of vision. When the lens is incarcerated in the pupil or it becomes opaque, it may be proper to dispose of it by discission or extraction, according to the age of the patient.

When the dislocation is into the anterior chamber, an effort may be made to reduce it by gentle pressure or rubbing over the cornea, either with or without a scleral incision behind the ciliary body to diminish the tension.

Should reduction be impossible and much irritation or inflammation be present, the lens should be extracted through a corneal incision. It may be supported during the operation by the " bident " of Agnew.

A lens dislocated into the vitreous chamber need not be disturbed unless irritation or inflammation take place, and then attempts may be made to extract it. This, however, is an uncertain procedure, especially with a floating lens, which it is almost impossible to “fish “out.

In any form of dislocation of the lens its extraction is necessarily followed by loss of vitreous humor (see also page 582). Rupture of the Capsule of the Lens. When the capsule is torn, whether anteriorly or posteriorly, the lens gradually becomes opaque. The rapidity with which this takes place depends upon the size of the rent. In some cases, where the latter is very small, it closes and heals, and the opacity remains partial. To the symptoms of cataract are added those of the irritant effects of swelling of the lens or the exuding of its substance into the aqueous humor.

The pupil should be kept as widely dilated as possible by atropin, and the lens should be extracted when its swelling causes dangerous reaction.

Contusion of the Lens. The lens may be bruised or contused without rupture of its capsule. It is followed by opacity, with all the symptoms of non traumatic cataract.

The treatment is that of spontaneous cataract.

Penetrating Wounds of the Eyeball. Penetrating wounds of the eyeball are generally situated in its anterior part, and most frequently in the cornea or corneo scleral junction. They assume great varieties of form, size, and shape, some being so small as scarcely to be traced, and others so extensive as to destroy a large portion of the eyeball. They may be limited to the cornea or sclera alone, or they may extend deeper into the iris, lens, and the structures beyond, and even pass through the eye into the orbit.

Symptoms. The symptoms vary with the nature and depth of the wound. When the penetrating object is small only a minute corneal opacity or abrasion or opacity of the lens will mark its course. But when a wound is of larger size it is readily seen; the evacuation of a portion of the intraocular fluids causes the eyeball to become softened, and there may be prolapse of the subjacent structures. Hemorrhage into some part of the eye usually takes place. Careful examination should be made for rents in the iris, opacities of the lens, and lesions in the fundus when the parts are not ob using the ophthalmoscope and oblique illumination for this purpose.,

The effect of penetrating wounds upon the state of vision depends upon the nature of the lesions present. These may be so slight as Dot to disturb vision at all, or, if disturbed, only for a brief time ; or they may be so extended that the vision is totally and permanently lost. Very little, if any, pain is experienced, unless inflammation develops.

In all penetrating wounds there is great danger of infection, and inflammation, with or without suppuration, is therefore a frequent sequence. An exuding and swollen lens is also a potent cause of iritis and cyclitis.

Prognosis. The prognosis depends very much upon the situation and nature of the wound. Opacities of the cornea and lens may obstruct vision, and injury of the retina in the macular region, very large hemorrhages, or great loss of vitreous may at once destroy it. An inflammation of the iris and ciliary body, caused by a wounded lens, is very liable to lead to obstruction or closure of the pupil and softening and shrinking of the eyeball. Punctured, ragged, or gaping wounds of the ciliary body are always serious, and they especially predispose to inflammation of the fellow eye (page 347).

Treatment. In all cases the strictest antisepsis should be observed. The wound should be freed of all included structures by excision or replacement, made scrupulously clean, and, whenever possible, closed by sutures and conjunctival flaps. When sutures cannot be used the lips of the wound may often be approximated or completely closed by a compress bandage over the eye.

Hemorrhages and inflammatory reaction are to be treated as elsewhere indicated. In some cases it is best to perform an iridectomy and extract a wounded and swollen lens. This will sometimes save the eye, but it more often fails. On this subject that master of ophthalmology, Arlt, has said : " Stich removal of the lens is to be considered more as a doubtful remedy as we seldom succeed in removing the lens as a whole, or even its greater part, and thus do not obviate the dangers of mechanical irritation or of increased pressure; perhaps, indeed, we even increase them."

The causes of sympathetic inflammation not usually being operative during the first two or three weeks, an effort may be made in some cases to save the wounded eye. Should improvement be rapid during this period, should no symptoms of cyclitis appear, and especially should there be promise of serviceable vision, such effort may be continued, but always with a great deal of caution. On the other hand, should cyclitis of the injured eye develop and continue, and especially should vision be hopelessly lost, enucleation or evisceration should be performed before the expiration of three weeks.

There are cases in which the eye is so seriously wounded that no attempt should be made to save it, but enucleation or evisceration should be done without delay.

Foreign Bodies on the Conjunctiva and Cornea. Minute bodies of various kinds may become lodged on the conjunctiva beneath the lids (usually the tipper one near the center), or on the cornea, becoming imbedded in its epithelium. When the force is sufficient, as in explosions, they may be driven deeply into the corneal substance.

A foreign body on the conjunctiva alone is scarcely felt, but when on the cornea or rubbing against it, it produces a scratching or pricking pain, which is not usually severe. There is considerable lachrymation and the eye becomes red. If the body is not removed soon, it may excite inflammation, particularly if it is on the cornea. In the latter case also it may cause ulceratioii of the cornea at the point where it is lodged. This sometimes extends and causes destruction of the eve.

The foreign body is detected by careful inspection, aided, if necessary, by oblique illumination.

Treatment. A body which is not imbedded deeper than the epithelium of either the conjunctiva or cornea should be picked away with some sterilized, sharp pointed instrument. When one is driven into or beneath the ocular conjunctiva, it may be excised, taking with it the least possible amount of this membrane. When it is imbedded in the substance of the cornea, it should be picked out with as little injury as possible to the surrounding tissue. It is generally impossible to remove grains of powder in this way, and they can be allowed to remain without danger of ulceration or suppuration. They simply leave black stains. Dr. Edward Jackson of Philadelphia has suggested burning them out with a galvano cautery point. But such a point must be very small and used with great care, or tile effects of the burn will be worse than those of' the powder. It should Dot be forgotten that more than one body may be present at the same time.

Foreign Bodies within the Eyeball. Any small, hard object, such as a splinter of wood, scale of iron or steel, spicule of brass or copper, fragment of stone or glass, may be projected with sufficient force to penetrate the coats of the eye and become lodged at any point within them. It usually enters through the anterior part of the eye, and most frequently through or very Dear the cornea.

Symptoms. The symptoms are essentially those of a penetrating wound, to which are added such a , are caused by the presence of the foreign body. The latter are at first negative, but later unusual irritation and inflammation develop, with corresponding symptoms.

Diagnosis. The history of the accident is of great importance. The circumstances under which it happened, the occupation engaged in, tile small size of the object striking the eye, tile direction of its course, whether or not it was seen after striking the eye, the immediate effect oil vision, and kindred information, should be ascertained, if possible. Unfortunately, such information is often very incomplete.

If, at the time of an, explosion of a percussion cap or the discharge of a shot gun, or while hammering iron or steel or cutting stone, a small object that was not afterward seen has struck the eye and perforated the cornea or sclera, the probability that it has entered the eye is so strong as to become almost a certainty. The reason of this is apparent when it is remembered that the resistance of the intraocular fluids is not sufficient either to check the course of the body or to cause it to rebound, and a force which was great enough to cause it to cut through the tough, outer coat would carry it farther into the eye after the opening was made.

With such a history and the presence of such a wound most careful search should be made for a foreign body. Hemorrhages, corneal irregularities, and opacities of the lens or vitreous humor greatly obstruct the examination ; but when the media are not obscured, and when tile object is not bidden by its position or by exudates, the ophthalmoscope and oblique illumination will often convert the suspicion of its presence into a certainty. A metallic object in the vitreous chamber gives a lustrous reflection when seen with the ophthalmoscope.

When, from any cause, a foreign body cannot be seen, it may in rare instances, if of considerable size and near the surface, be felt by a probe but this should be used with great caution.

the body is steel or iron the etectro maqnet will often assist in diagnoosis. A strong one applied to the surface of the eyeball will sometimes attract the iron or steel, and the movement of the latter will cause more or 4 pain. Or, if the wound is so situated as to warrant it, an extension of the electro magnet of suitable size may be carefully introduced into it when it will sometimes not only attract the body to the surface, but bring out.

The zpevial adaptation of Rontgens's rays, or skiagraphy, to the eye will ofentimes demonstrate the presence of a foreign body and also its approxi mate position (see Appendix, pages 607 611).

Should it be impossible by means of sight, touch, the electro magnet, or skiagraphy to ascertain the presence of a foreign body beyond doubt, the presumptive diagnosis of its presence based upon the history and conditions above outlined should prevail. In case of delay such symptoms of irritation and inflammation may set in as could scarcely be expected as a result of the wound alone. These will strongly corroborate the other evidence of tile presence of a foreign body. The eye may, however, remain quiet in exceptional cases, but this is not sufficient to outweigh the primary evidences and to nullify the diagnosis of a foreign body in the eve.

Prognosis. When a foreign body is lodged in the eye the consequences of a penetrating wound follow which have already been considered, together with those arising from the presence of the foreign body itself.

As regards the latter, it may be said that, however small the body may be, whatever may be its substance, and wherever it may be situated ' it sooner or later, with rare exceptions, causes destructive inflammation of the injured eye, and may also induce sympathetic inflammation of the other. The only structure which will tolerate a foreign body without danger of inflammation is the lens. Even here vision is obscured by the lens becoming opaque.

Cases have been recorded in which the membranes of the eye or the iris have tolerated a foreign body for a long period of time, or in which one has become encysted and remained harmless, or in which one has been spontaneously expelled; but they are so rare as not to have material weight in prognosis or treatment. In every ease it should be assumed that the eye is sure to be lost unless the offending body is removed. After its removal the eye is in the condition of one with a penetrating wound, and may or may not be saved according to the circumstances of the case.

Treatment. In some cases, although the foreign body may be found and removed, the injury is so extensive that the eye is hopelessly lost. Immediate enucleation or evisceration is then the safest procedure. But when the nature, of the injury will permit, all reasonable effort should be made to remove the foreign body and save the eye with as much vision as possible. When the presence and location of a foreign body have been determined, the course to pursue will depend on what substance it is and on its position. If situated in the anterior chamber or iris, it may be extracted with or without excising a piece of iris through an incision at a suitable point in the cornea. If lodged in the lens, it may be left there until the latter has become fully opaque, and then both may be extracted together. Or, should the wounded lens become absorbed, the foreign body may then be treated as if it were, from the first, lodged in the anterior chamber or perhaps in the vitreous humor.

When a body is lodged in the posterior part of the eye it may sometimes be caught by forceps (without teeth), books, or scoops, and drawn out. But such a happy result is not often obtained.

Should the foreign body be steel or iron, the electro maqnet (Fig. 237) is of great service, and the chances of extracting the fragment are increased many fold. Very large and powerful electro magnets, which have lately been introduced by Haab, are not often available, and the smaller instruments give eminent satisfaction. The electro magnet should be armed with as short, and also as large, an extension point as can be consistently introduced, since the attractive force is diminished very rapidly as the point becomes smaller and longer. The point should also be flattened or squared, instead of rounded, to give as much surface contact as possible. A rounded point reduces this to a minimum.

The extension point may be introduced through the original wound, or, which is often preferable, through an incision suitably located and made for the purpose. It should be carried, without twisting it or changing its course, toward the supposed or known position of the fragment and reintroduced if necessary. Should it attract the steel or iron or in any way come in contact with it , it will generally produce a distinct click which can be both felt and heard. On withdrawing the point the steel or iron is brought out with it, or perhaps it is held back at the wound, when the point should be partially reintroduced, and the extraction then assisted by forceps made of some other material than iron or steel.

removal of the foreign body the case becomes one of a penetrating wound of the eye, and should be treated accordingly.

Should it be impossible to remove a foreign body whose presence is extremely probable or definitely determined, the vision being without doubt permanently lost, the eye should be enucleated or eviscerated. A delay, however, may be made for a short time, as in penetrating wounds, when there remains some vision and the diagnosis is doubtful. Rapid improvement and absence of symptoms which point to sympathetic disease may justify still further delay, but with a continuance of inflammatory symptoms and a progressive deterioration of sight, if this was not destroyed at first, the delay should not extend beyond two or three weeks, as after this time sympathetic inflammation becomes imminent at any moment.

Injuries of the Eyelids and Lachrymal Passages. Ecehymosis of the eyelids follows contusions and wounds, and also hemorrhages into the orbit and around the eyeball. The discoloration of the skin varies in depth and extent with the amount of blood extravasated. There is, occasionally, swelling of the parts and a feeling of stiffness, but no pain. The blood is absorbed, and the skin regains its normal color in from one to three weeks.

Very little treatment is necessary. Absorption of the blood may be hastened by bathing the parts with water as hot as can be borne and by gentle frictions.

Emphysema of the eyelids may take place when the. mucous membrane of the nose becomes torn in connection with a fracture or injury involving the nasal cavities, and a communication is established between the latter and the cellular spaces of the lids, and air is forced into them by blowing of the nose. The parts are immediately puffed up into a soft, crepitating, and painless swelling.

The patient should be cautioned against further blowing of the nose till after the wound is healed. A compress bandage should be applied over the lids, and the air will be absorbed in a few days.

Contusions the lids are generally followed by ecchymosis with some swelling and soreness. They should be treated by cold applications, unless suppuration takes place, and then warm fomentations should be used, and the abscess opened early by incision.

Punctured wounds are generally of little consequence, but the incised and lacerated varieties, especially the latter, require careful attention. When a wound runs parallel with the edge of the lid it will unite without deformity. But when it extends across the orbicularis muscle or through the margin of the lid, the wound gaps, and if not closed by surgical measures leaves a depression of the surface or a permanent cleft through the edge of the lid. When the lachrymal canals are severed they become permanently closed.

The utmost care should be taken to close all gaping wounds and to restore to proper position displaced parts. The loss of skin may call for a plastic operation. When a lachrymal canal has been severed, it should, if possible, be searched for and slit up and kept open.

Foreign bodies mav become lodged beneath the skin, and should be removed by cutting down upon them and picking them Out.

They may also get into the lachrymal punctum or canal, and cause irritation of the ball by rubbing against it, or stillicidium by obstructing the passage. They are easily withdrawn when they are in sight, but when not it will be necessary to slit open the canal and then remove them.

Injuries from hot substances and escharotics produce the same symptoms and require the same general treatment as those occurring elsewhere on the surface of the body (see Fig. 238). The unsightly and distressing deformity and loss of function which follow cicatrization should be prevented by skingrafting, preferably by Thiersch's method. To this end, as soon as the eschar is thrown off and the granulating process is well established, the affected surface should be scraped, and the grafts applied as described in surgical treatises. This part of the treatment cannot be too forcibly urged.

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