Intra-orbital hemorrhage is not uncommon after injuries to the head. It may result from rupture of orbital vessels proper or by escape of blood from within the cranium, either outside or beneath the dural prolongation which constitutes the sheath of the optic nerve. When extensive it may produce a pulsating tumor, and this may, in time, become practically a traumatic aneurysm. After basal fractures blood frequently will escape forward so as to appear beneath the conjunctiva. Collections of blood in the orbit may also interfere with the return circulation in such a way as to lead to extensive chemosis of the conjunctiva or edema of the lids and orbital contents. Pressure may cause temporary disturbance of vision. Should there be absolute blindness it may be inferred that there has been injury to some part of the optic tract. Protrusion of the globe is an indication of the degree and amount of extra-ocular hemorrhage, which may be very pronounced. When visual symptoms are bilateral, while external evidences are confined to one orbital region, it may be assumed that there has been intracranial disturbance as well, with laceration along the optic tract. Such immediate damage will in time be followed by the ordinary symptoms of neuroretinitis and atrophy.
The more external the injury the more quickly will it yield to ice-cold applications. There are times when incisions for relief of tension may be desirable. An extensive clot in the orbit which seriously displaces the eyeball, and which does not quickly absorb, should be evacuated by an incision, either directly through the lid or beneath the lid and outside of the globe.
Penetrating injuries, like gunshot wounds, are usually easy of recognition. If vision be instantly and completely lost the harm done to the optic nerve or the globe will probably prove irreparable. Foreign bodies penetrate from various directions, and sometimes to such a depth that they are difficult to find. I have seen a large chip of wood completely lost within the orbit, and such bodies may enter either from outside or from within the nasal cavities. A foreign body will nearly always limit the motility of the globe and usually displace it. If its presence can be ascertained or revealed before operation it should be sought and removed at the expense of almost any and every other indication. If its presence be suspected it may be sought for, even though a skiagram fail to reveal it. When the usefulness of the eye is destroyed it will be advisable in such case to remove it in the progress of this search.
Aside from the traumatic hematomas above mentioned extravasation occurs, due to constitutional or vascular disease, as atheroma, especially when coupled with violent straining efforts. Subconjunctival effusion and exophthalmos, with limitation of motion, will be unfailing expressions of such damage. Orbital aneurysms, spontaneous or traumatic, are occasionally seen. They will cause a more or less pulsating exophthalmos, while, in some instances, a bruit may be detected with the stethoscope. Cases may be imagined where it would be suitable to cut away the external wall of the orbit and expose such a tumor. Ordinarily, however, ligature of the internal or common carotid will be required. Angiomas occur also in the orbit, producing exophthalmos, usually without pulsation. Such tumors will prove compressible and the globe may be gently pressed backward into the orbit to immediately protrude again when pressure is removed. These lesions will prove very difficult, usually impossible of treatment, and no general rule can be made therefor.
Orbital cellulitis, i. e., infection of the cellular and other tissues in the orbit, may occur, either from without or from within, but usually in connection with some traumatism. Sometimes this involves first the cornea or the structures of the globe; at other times infection is by a more direct method, through the conjunctival sac or the orbital coverings. It varies in intensity between extreme limits. It may even be bilateral. While cases occasionally undergo resolution it usually terminates by formation of abscess. It is met with in the infectious fevers, in facial erysipelas, by extension upward of infection from diseased teeth, after primary infection of the ethmoidal or sphenoidal sinuses, or by extension from external phlegmons. There will be edema of the lids, usually with chemosis, fixation and protrusion of the eyeball, commonly with divergence. In proportion to the severity of the lesion there will be present septic symptoms, with deep-seated pain and headache. Vision is disturbed in proportion to the pressure upon the nerve and globe, as well as the involvement of the ocular structures proper. When the disease is begun within the eye it will usually terminate by a combination of panophthalmitis with orbital abscess.
—The application of the compound ichthyol or Credé’s silver ointment, with ice, preceded perhaps by the use of leeches, will be suitable local treatment unless the presence of pus be distinctly made out or until tension threaten serious harm. In either of these events, however, free incisions are required at points of greatest tension, the knife being so directed as to avoid the globe. These incisions should be free and sufficiently deep. Should there be accompanying panophthalmitis the eyeball itself should be freely incised through its anterior aspect and its contents completely evacuated. Such emptying of the contents of the sclerotic is called evisceration of the globe. While theoretically indicated, experience has shown that it is a disastrous practice to enucleate the eye at such a time; evisceration first and enucleation later, should it prove desirable.
The orbit is the site of many primary tumors which originate within its proper tissues as well as those which encroach upon it from neighboring cavities or from the face. Prognosis is better in the former than in the latter, but unfavorable in all malignant cases.
Of the primary cystic tumors there may be nearly all the known varieties, including those of parasitic origin. The pseudocysts of the cranial cavity sometimes project into the orbit, forming orbital encepholacele. Dermoid cysts are not at all uncommon. Around the bursæ of the orbital muscles exudation cysts occur, while the retention cysts, including the cholesteatomas, are not infrequent. The true dermoid cysts may contain all the ordinary epithelial products, just as in any other part of the body. Parasitic cysts include the echinococcus and the cysticercus, the latter being rare, while the former may extend into the frontal sinus or cranial cavity. It produces almost constant ciliary neuralgia. Vascular tumors of all types are found in the orbit and the various expressions of telangiectasia of the lids and orbit are often seen. These are always of congenital origin. Of the more simple types of mesoblastic tumors the osteomas are perhaps as common as any. These assume all the types described in the chapter on Tumors, and are of all degrees of hardness. Sarcoma and osteosarcoma, originating within the orbit, are unfortunately too common. Naturally they spread to and involve all the adjoining structures. True endothelioma is rarely recognized as such until after removal and microscopic examination. Epithelioma commencing upon the surface of the eye, or about the skin and spreading inward, is also quite common.
Exophthalmos is an expression of intra-orbital tension common to all forms, while by the extent of protrusion and its direction the site of the tumor may to some extent be determined. Other disturbances of position, with limitation of motion and consequent diplopia, are further expressions of pressure and dislocation. Ptosis, or drooping of the upper lid, is a feature of tumors which proceed from the upper part of the orbit. The vascular tumors, as already mentioned, produce more or less pulsation. Ocular tension is usually increased, and when circulation and enervation have been seriously affected necrosis and even perforation of the cornea may occur. Pain is a variable feature, but is sometimes pronounced. An exploring needle may be passed into a tumor which seems to be cystic, but it should be done with every precaution, both against infection and injury to the eye.
Tumors of the optic nerve proper originate more often in its sheath than in its true neural tissue. They may occur at any point, but usually within the orbit. These tumors are usually of the sarcomatous, gliomatous, or endotheliomatous type. Cystic changes are not infrequent; they occur usually in the young. All of these tumors will involve the optic nerve in such a way as to produce signs easily recognizable with the ophthalmoscope, such as optic neuritis and nerve atrophy. Moreover, they affect or completely destroy vision. They are not so painful as most of the other intra-orbital tumors, and, while causing a direct forward protrusion of the eye, affect its motility less than other forms. Nevertheless they grow with great rapidity and evince destructive tendencies. In theory the treatment for all tumors of the orbit is complete extirpation, while the malignant tumors require emptying of the orbital contents. Benign tumors and cysts are usually successfully treated by this method. Of most malignant tumors it may be said that the prognosis is unfavorable. The lymphatic and vascular connections are so free, and extension into surrounding cavities so easy, that recurrence takes place in the larger proportion of cases. Too often by the time a patient is willing to sacrifice the eye and the orbital contents it is too late to effect a radical cure.
The term exophthalmos simply implies protrusion of the eyeball beneath and even between the lids. Usually it is in a downward and outward direction. In some cases the displacement is accompanied by an easily recognizable pulsation, and occasionally by a bruit or audible sound. The latter instances are spoken of as pulsating exophthalmos. They are connected in most cases with vascular tumors or intra-orbital aneurysms, although sometimes the aneurysm may be primarily intracranial. For instance, arteriovenous aneurysms, by communication of the internal carotid artery with the cavernous sinus, will produce pulsating exophthalmos. Whatever be its cause exophthalmos is an expression of pressure from behind. This is true even of the ocular symptoms accompanying Graves’ disease or exophthalmic goitre, only here the protrusion is permitted by general fulness of the vessels and undue vascularity of the orbital tissues.
In proportion to the amount of projection there will be swelling and edema of the upper lid, the skin being more or less shiny and the veins distended. In extreme cases the lids are everted and the conjunctiva extremely chemotic, while by exposure of the cornea it becomes vascular, infected, and often necrotic. Should it be possible to replace the globe by pressure it will protrude so soon as pressure is removed. In vascular cases a bruit may be heard and pulsation detected with the finger. Audible sounds are lost by making firm compression on the common carotid of the same side, and return instantly when this pressure is removed. By the ophthalmoscope both arterial and even venous pulsation may be perceived at the fundus. Vision is only slightly affected by a well-marked protrusion, especially when the latter has occurred slowly. The pulsating forms will frequently give subjective symptoms of sound and sense, e. g., vertigo.
A history of injury, coupled with external evidences, may give a clue to some of these cases as an indication of traumatic aneurysm or communicating vascular tumor. Soft and vascular tumors, without history of injury, are usually malignant, this being true also of multiple growths.
—The treatment of exophthalmos should depend entirely on its nature. When due to arteriovenous aneurysms, or to the consequences of injury alone, a ligation of the common or of the internal carotid will give the best result. When compression of the carotid gives temporary relief to at least some of the features of the case its permanent ligation is indicated. Bilateral exophthalmos implies a more serious condition, especially in Graves’ disease. When thyroid symptoms are prominent a thyroidectomy is indicated. When the thyroid participates but slightly such a case may be treated by excision of the cervical sympathetic on both sides.
These tumors may assume most of the known types and may spring from practically all of the tissues of the eye.
From the iris there may develop cysts of traumatic or even of congenital origin. In the former such a foreign body as an eyelash may be found, having entered through an external wound of the cornea. Vascular tumors are occasionally met with, many of which are full of pigment, while melanomas, with a minimum of vascular structure, are also observed. The actively malignant tumors of the iris usually assume the sarcomatous or endotheliomatous type, and when melanotic assume an exceedingly rapid and serious phase and course. In the iris, also, tuberculous or syphilitic granulomas are occasionally encountered.
In the choroid are seen expressions of tuberculosis, especially the more acute, as a complication of tuberculous meningitis. The most common malignant tumor here is sarcoma of the melanotic variety. Of the retina, glioma is the most common as well as the most malignant tumor, occurring usually in the young. All of these tumors when malignant spread from their primary site to the adjoining tissues. When extremely malignant they kill too quickly to show many metastatic expressions. At other times they will appear in other parts of the body.
All intra-ocular tumors tend to impair, and the malignant to quickly destroy vision. Tension is increased and the natural contour of the globe may be lost. Fixation to and involvement of the surrounding orbital tissues depend in some measure on the rapidity of growth and its location. They occur sooner or later in malignant cases.
A malignant growth of any part of the globe calls for enucleation of the eye, as well as removal of the orbital contents. When the orbital tissues are thus involved it is too late to secure more than temporary benefit. If the eyelids are involved they should also be sacrificed and the orbital opening covered by some plastic procedure.
The term panophthalmitis implies a phlegmonous process involving the entire contents of the sclerotic, by which the eye is destroyed. It is usually traumatic in origin, but may occur as an extension of infection from ulcer and abscess of the cornea, or from thrombotic or metastatic processes. Its course is usually rapidly destructive, while it is accompanied by more or less orbital cellulitis. These signs, therefore, are not confined to the orbit proper, for the lids become edematous, the conjunctiva chemotic, and there is more or less purulent discharge from the entire conjunctival sac, which will escape beneath the lids. If the cornea is at first clear it rapidly becomes cloudy, and to the signs of intra-orbital mischief are added all those above described under the heading of intra-orbital cellulitis. The sclerotic is an unyielding membrane; hence pain in these cases is usually intense, while septic features are added according to the nature of the cause. When the lesion has begun in the cornea it usually ruptures early and the ocular contents may escape in this way.
—Panophthalmitis is dangerous to life as well as to the eye when not promptly treated. The same rule prevails here as well as elsewhere in the presence of pus. Prompt evacuation offers the greatest safety and relief. Evacuation of the entire contents of the eye through a free incision and by means of a sharp spoon, with antiseptic irrigation, affords the only safe measure in these cases.
As previously remarked, the general consensus of opinion among oculists and surgeons is that, under these circumstances, enucleation should never be done, the danger being that of a purulent meningitis or thrombosis by extension backward along the sheath of the optic nerve.
This, too, is a matter of interest common to the eye specialist and the general surgeon. The term refers to lesions of one eye which follow sooner or later upon injuries or infections of the other. These expressions of so-called sympathy occur in irritative or inflammatory lesions. The former are more or less neurotic and include pain, often referred to the region beyond the orbit, photophobia, blepharospasm, too free lacrymation, and various subjective phenomena of impaired vision. These features will be accompanied by more or less tenderness of the globe, with ciliary neuralgia and injection. These may subside under treatment, but will recur when the eye is again used.
Contrasted with these lesions is another form whose features are most pronounced along the uveal tract, though the retina may also suffer. Its subjective features are those of uveitis, to which are added actual exudates in various parts of the globe, some of which may be seen with the ophthalmoscope, with intra-ocular tension, which reduces the anterior chamber, and with partial or complete loss of sight that may end in total atrophy. In some instances these lesions occur rapidly; in others the course of the disease is chronic.
The oculopathologists have striven hard to explain these phenomena. Most of them believe in the continuity of the subdural or subvaginal sheath of the nerve from one orbit around into the other, and believe that the germs passed along this subway. Involvement of the yet unaffected eye may follow the entrance of foreign bodies, occurrence of traumatisms, punctures, existence of corneal lesions as minute ulcers, constant irritation of the presence of an artificial eye upon the stump, the performance of some of the common operations upon the globe, and even the much less frequent conditions of pathological changes in the choroid, the ciliary body, the optic nerve, or the existence of intra-ocular tumors. A recognition of the possibilities in these cases will lead to more radical treatment of the lesions which may produce them. Even a minute foreign body should be promptly removed and an ulcer of the cornea should not be regarded as a trifling lesion. Under all circumstances the surgeon, as well as the general practitioner, should be alert to the possibilities of these lesions, quick to recognize the symptoms, and prompt in urging the only satisfactory relief. It will be seen that the earliest suggestive features are those of involvement of the uveal tract.
—There is usually but one efficient method of treatment for these cases, and this consists of removal of the injured or diseased other eye, more particularly if it be more or less already impaired by the consequences of the original lesion. The exceptions to this statement occur in the event of well-marked sympathetic inflammation, as it may be possible that there will be better vision in the originally injured eye than in that secondarily infected; but so long as it is a matter of simple sympathetic irritation enucleation is the proper course. While this is extremely radical there is no satisfactory substitute for it. The only excuse for delay should be threatening phlegmonous processes by which communication posteriorly might be afforded. Bull has laid down the following indications for enucleation of the first eye before the outbreak of sympathetic inflammation in the other eye:
1. When the wound is in the ciliary region, and so extensive as to greatly damage or entirely destroy vision;
2. When the wound is in the ciliary region, and is already accompanied by iritis and cyclitis;
3. When the eye contains a foreign body, and attempts at its removal have proved futile;
4. When the eye is atrophied or shrunken and tender on pressure, or is continually irritated.
The conditions which justify enucleation of the eye have been pointed out. For the operation, which is usually done under general anesthesia, the lids should be widely separated with the ordinary eye speculum or by suitable retractors. A circular incision is then made through the conjunctiva, around the margin of the cornea. This is carried down to the sclerotic at a little distance from the corneal margin, by which Ténon’s capsule is opened; then a strabismus hook is inserted in each direction and the tendon of each muscle raised upon it and divided close to its insertion. By pressure upon the surrounding tissues the eye is now made to protrude. Should the globe have been already collapsed it should be drawn forward with forceps, one blade of which may be thrust within it. After thus firmly withdrawing it a blunt-pointed, curved scissors is passed behind and around it, the blades being made to open in such a way as when closed to divide the optic nerve at a little distance from the globe. After this enucleation by pressure is easy, and any further tissues requiring division may be readily cut. The principal source of hemorrhage is the artery extending through the nerve, but this is readily controlled by pressure.
Should there have been any inflammatory or septic condition about the orbit or the conjunctival sac the parts should be cleansed with hydrogen peroxide or other antiseptic. Sutures are seldom required. A compress should be applied outside the eyelids, removing it sufficiently often to be certain there is no retention of fluid or blood.
Recovery is usually rapid. Granulation tissue sometimes forms at the bottom of the conjunctival sac and becomes exuberant. In this case it should be removed with scissors and cauterized, after which it rarely recurs.
As already described, many expressions of the various stages of syphilis pertain to the eye. Thus there may be chancre upon the eyelid or conjunctiva, or ulceration of the same; syphilitic iritis as a secondary expression; syphilitic retinitis, neuroretinitis, choroiditis, as tertiary lesions; and the formation of gummas in the later stages of the disease, and in almost any imaginable locality, especially the uveal tract. Syphilitic tumors are seen upon the iris more often than anywhere else within the eye. Outside of the globe and within the orbit the ordinary expressions of syphilitic periostitis and of gummatous tumors occur. These constitute also the more common intra-orbital expressions of this disease.
The symptoms of syphilitic lesions in this location do not vary from similar lesions elsewhere, save so far as they involve special tissues or disturb the special sense of sight. The prognosis in nearly all of them is relatively good if suitable and active treatment be promptly instituted. It is, however, too much to expect that annular destruction of areas of the retina or choroid can be completely repaired.
Cataract is a subject of primary interest to the general surgeon only so far as it pertains to the consequences of injury to the orbital region. The term implies opacity of the lens or of its capsule, or both, which may be partial or complete. Its pathognomonic feature is slow and progressive failure of vision. Examination by direct as well as bilateral illumination will show the opacity to be located behind the iris. Everyone should be able to recognize it; its excision should be relegated to the trained specialist, since it is one of the most delicate special operations.
The term glaucoma implies a collection of more or less variable pathological conditions within the eyeball which lead to increased intra-ocular tension. Because of this increased pressure, with its disturbance of circulation and the peculiar coloration often given to the cornea or the pupil, the disease has received this name. Among its symptoms are pupillary changes, including both size and mobility of the iris; turbidity of the cornea, as well as the fluid humors of the eye; pain, corneal anesthesia, impairment or final loss of vision, engorgement of the visible vessels of the globe, and a peculiar cupping or excavation of the optic disk. Unless checked by operative intervention the course of the disease is steadily toward blindness. It varies in acuteness, the favorable cases being the acute ones, in which early operation can be practised. It admits of no other treatment.
—The operation almost universally practised by the oculist is either iridectomy or sclerotomy. The condition is briefly mentioned in this place for the double reason that the student may be made aware that the condition may follow certain injuries to the eyeball or the head, and that the more chronic forms have been successfully treated by excision of the cervical sympathetic, on one side or both, the operation being based upon anatomical and physiological facts pertaining to the distribution and function of those sympathetic fibers which pass to the orbit from the cervical trunk. The operation is described in the section on the Cranial and Cervical Nerves.
These lesions are frequently the result of blows and of penetrating injuries, as well as of syphilis. Moreover, motility of the iris is so essential to the normal function of the eye that where it may possibly be effected the surgeon should protect against those adhesions between the iris and the lens or cornea, which are very likely to occur, by instillation of a sufficiently strong solution of atropine, a ¹⁄₂ to 1 per cent. solution being usually sufficient for this purpose. These adhesions are referred to as synechiæ, and are anterior when the iris becomes affixed to the cornea, or posterior when affixed to the lens. They occur easily after minute punctures of the cornea, the result being a limited mobility or a dislocation of the pupil, along with opacity of the cornea, all of which work to the detriment of vision.
The iris is so visible that the mechanism of an exudate on or in it can be observed almost from beginning to end when it occurs in the form of iritis. Occasionally an exudate will merge into an actual collection of pus which will gradually fill up the anterior chamber, and which is then spoken of as hypopyon. Under the most favorable circumstances a disappearance of this pus by absorption may be noted. It may prove destructive or may necessitate evacuation.
The iris and the ciliary body are intimately connected, and inflammation beginning in one point may easily spread to and involve other tissues. These structures with the choroid constitute the so-called uveal tract, and when they participate in inflammation it is called uveitis.
The symptoms of iritis consist of pain, lacrymation, photophobia, which is often intense; increasing turbidity of the aqueous humor, as well as of the cornea, by which vision is impaired; visible discoloration; irregularity and sluggishness in movements of the iris, and circumcorneal injection. A congestion which assumes an annular form about the cornea and does not involve the conjunctival sac indicates trouble in the ciliary region, while a true conjunctivitis is limited only by the extent of the membrane itself.
Iritis due to syphilis, whether assuming the plastic or the gummatous form, requires the most active antisyphilitic medication, in addition to local treatment. The non-specific and traumatic forms need absolute rest in a dark room, with cold applications about the eye and the free use of atropine, to completely dilate the pupil and prevent the formation of synechiæ.
The cornea being the most exposed part of the eyeball will be frequently subjected to minor or serious injury in connection with violence to the orbital region. It is an exceedingly sensitive membrane, whose reflex excitability is heightened by the presence of a small foreign body, this accident being one of frequent occurrence. It is a lesson in neurophysiology to watch the relatively local and general disturbances which the presence of a minute speck of foreign material embedded in the cornea may cause. Every extraneous body should be removed at once, the procedure being now facilitated by the local use of cocaine, for any abrasion or serious injury of the cornea occurring in surgical cases offers a possible source of infection to the deeper ocular structures. Careful attention should be given to the use of antiseptics of suitable strength in the conjunctival sac, whenever this region is involved. This statement cannot be made too positive. There is danger both to the cornea and to the iris in perforating ulcer or traumatism of the cornea, and there is as much occasion for the use of atropine in these instances as in those pertaining to the iris proper. To the protrusion of the cornea, which is produced by weakening of its structure and tension from within, is given the name staphyloma. It is frequently combined with adhesions of the iris and dislocation of the pupil. It constitutes not only a cosmetic disfigurement, but a serious impediment to vision.
PLATE XLV
FIG. 1
Lacrymal Fistula on the Right Side; Ectasia of the Lacrymal Sac on the Left; Bilateral Epicanthus. (Haab.)
FIG. 2
Dacrocystitis. (Haab.)
The mucous membrane lining the conjunctival sac is perhaps the most exposed to irritation and even infection of all mucous surfaces. It is not strange then that conjunctivitis is the most common of all eye affections. Whether irritated by constant exposure to dust and dirt, or raw and cold winds, or by the heat of a blast furnace, by the dazzling brilliancy of electric lights, or contact with bacteria, it displays a surprising degree of accommodation and resistance. It has peculiar susceptibilities, particularly to the germs of gonorrhea and diphtheria. To these it is peculiarly sensitive, and under their influence it may quickly succumb. The harm done in either of these conditions is by no means limited to the conjunctiva, but may extend in such a way as to eventually cause loss of vision.
Nowhere else may the phenomenon of hyperemia be so easily studied as by watching the ocular conjunctiva for a few moments after the occurrence of irritation. The rapidity with which the vessels dilate and become visible, the occurrence of the consequent redness and swelling, and the reflex phenomena attending it become appreciable within a short time. In the chronic conditions the tissues become thickened and less mobile. A chronic conjunctivitis is the constant condition in certain laborers whose eyes are exposed in their occupation.
A peculiar granulomatous condition of the conjunctiva, especially the palpebral, is that known as trachoma, which appears to be due to a specific form of infection that leads to exudation, organization and thickening, intensified in punctate areas, and giving the surface the appearance of an ordinary granulation. This condition has assumed such importance as to be sufficient for the exclusion of aliens and immigrants.
The milder conditions of acute or subacute conjunctivitis subside under cold applications and mild antiseptic and astringent eye-washes or collyria. These should be frequently instilled, beneath the lid whenever this area is involved as a complication of injuries to the head or face. In acute cases of the infectious type, such as the gonorrheal or diphtheritic, atropine should be used locally, so that the iris may be drawn out of harm’s way and the pupil left free should resolution and recovery ensue. Individuals suffering from either gonorrhea or diphtheria should be cautioned and protected from possibility of conjunctival infection. The eyes of the newborn are not infrequently infected during the process of parturition. The parturient canal of women suspected of having an infectious lesion of this kind should be cleansed before the passage of the fetal head, and in all suspicious cases instant and constant attention should be given to the eyes of the newborn infant.
The lacrymal gland, though situated in the anterior and upper part of the orbit, and beneath the upper lid, where it is ordinarily well protected, is nevertheless liable to both acute infections and chronic irritations. When acutely inflamed it usually goes on to abscess formation. We have then acute dacryo-adenitis, which will produce the ordinary symptoms of phlegmon, with the added ocular features of vascularity and chemosis of the conjunctiva and more or less edema and immobility of the upper lid. Displacement of the eyeball may be produced by great inflammatory swelling. These abscesses tend to discharge either through the skin near the external angle or sometimes through the conjunctiva. While in the former case a scar results, it nevertheless is a preferable point either for spontaneous opening or for incision. If the case be seen in time it will be advisable to make this incision early and so limit destruction. (See Plate XLV, Fig. 1.)
The lacrymal gland suffers occasionally in instances of constitutional syphilis, undergoing chronic and obstinate enlargement. It may also be the site of tumors either non-malignant, usually adenoma, or cancerous, most instances of the latter being expressions of extension.
The tear passages proper are composed of the canaliculi, the lacrymal sac, and the duct. These are altered, occasionally, in their relations, or absent, as the result of congenital defects. The passages proper frequently become obstructed, as the result of any chronic irritation which produces thickening of the conjunctiva, and in many laborers and others who are exposed to dust, dirt, or cold winds there will be a more or less constant stillicidium or overflow of tears. In some of these cases it is sufficient to slit up one or both canaliculi with a fine probe-pointed bistoury.
The lacrymal sac proper is frequently the site of both acute and chronic disease, known as dacryocystitis, which is the result of infection spreading from the conjunctival sac, rarely from the nose, or the exaggeration of conjunctival thickenings, like those mentioned above. The first symptoms are overflow of tears, accompanied by swelling or enlargement in the region of the sac. By pressure upon this a mixture of water, mucus, and sometimes pus may be expressed. As the disease goes on the fluid becomes purulent. If the sac, by pressure, can be emptied into the nose the nasal duct may be regarded as patulous and the treatment is simplified. If not there is stricture, usually at the upper end of the duct, which requires division and dilatation. The more chronic forms of trouble in this region are frequently intensified into acute phlegmonous lesions which, if neglected, will lead to spontaneous perforation and the formation of a lacrymal fistula at a point below the inner angle of the eye. (See Plate XLV, Fig. 2.)
—The treatment should consist of exposure of the sac by incision of the canaliculi and its irrigation by means of a syringe and antiseptic fluid. Unless this fluid passes easily into the nose the stricture should be divided and Bowman’s probes passed, the principle of treatment being the same as that in treating urethral stricture. This part of the treatment should be referred to an oculist.
In acute dacryocystitis with suppuration the sac along the natural passages should be opened. When a diagnosis of an acute lesion of this kind is made nothing but the most radical treatment is advisable.
Congenital deformities of mild degree are not infrequent about the eyelids.
Epicanthis is a term implying folds of redundant skin extending from the internal end of each eyebrow to the inner canthus and over the lacrymal sac. It varies much in degree, is a more or less hereditary feature in certain families, and is not infrequently associated with other defects. The palpebral fissure varies in length in different individuals, giving a longer or shorter window through which the eye proper shall appear. Sometimes the fissure is much too short and requires division or extension, which is easily made by incision at the outer angle.
Coloboma is a term applied to various lesions of the eyelid, the iris, and the choroid, implying a defect in structure, which, in the eyelid, leaves a V-shaped deficiency, corresponding to harelip, whose edges may be brought together by a simple operation.
The eyelids are subject to certain painful or disfiguring lesions, which frequently come under the notice of the general surgeon. Of these the most common is stye, or hordeolum. This is a phlegmon of one of the minute glands along the margin of the lid, which has become infected and violently reacted. It forms a miniature furuncle, often associated with conjunctivitis, and giving a disproportionate reaction. So soon as the presence of pus can be detected a puncture should be made and the contained drop of pus exvacuated. Threatening suppuration may sometimes be aborted by local use of 1 or 2 per cent. mercurial (yellow) oxide ointment.
A somewhat similar but non-inflammatory cystic distention of one of the Meibomian glands, which pursues a slow and painless course, is called chalazion. It presents rather beneath the mucous surface, but is often visible through the skin. Its contents are mucoid or dermoid. When it attains troublesome dimensions it should be exposed through a small incision, usually external, and thoroughly extirpated.
Small, elevated areas of dirty-yellow color are met with in the skin about the eyelids, more often near the inner angle. Such a lesion is called xanthelasma, the lesion being a fatty metamorphosis of a portion of the skin structure. While harmless, it is amenable to excision for cosmetic effect.
Any of the ordinary tumors which affect similar tissues elsewhere may be seen about the eyelids. The more common are the vascular tumors, especially small nevi. Epithelioma occasionally commences along the palpebral margin, but is more often an extension from neighboring tissues.
The margins of the lids are frequently involved in a mildly infectious inflammatory condition called blepharitis, in which nearly all the structures participate; when the borders alone are involved it is referred to as blepharitis marginalis. The condition is largely due to dirt, and to irritation in which the Meibomian ducts seem to share. It is accompanied by chronic conjunctivitis. The condition is seen more often in the ill-nourished, the rickety, and the tuberculous. The best local treatment consists in the use of an ointment of yellow oxide or yellow sulphate of mercury. The former may be used in 2 per cent. strength, and the latter not stronger than 1 per cent. This should be applied along the lid margins at night, and thoroughly rubbed in. A commencing phlegmon and stye may be aborted by one of these preparations.
Another very annoying complication, and usually the sequel of the condition already mentioned, is trichiasis, or turning inward of the eyelashes. Chronic irritation and cicatricial contraction on the inner aspect of the eyelids, or a chronic blepharospasm, which may be the result of corneal infections, serve to draw the lids inward, especially with the margins of the hair follicles, so that the eye-winkers grow toward the ocular surfaces, which they constantly irritate. The result is a vicious circle, each morbid condition intensifying the other. In time there is produced a condition of entropion, which is to be remedied only by operation. It is not sufficient to treat trichiasis by epilation, as the hairs will grow again and continuously cause trouble. The cause should be removed and the effect treated.
By this term is meant a condition of inversion of the margin of one or both lids, by which the external surface is brought into actual contact with the surface of the eyeball. It is a chronic condition brought about through the action of several contributing causes. Any condition of the cornea or deeper portion of the eye which leads to photophobia and spasmodic closure of the eyelids will produce in time hypertrophy of the orbicularis, with corresponding strengthening of the muscle and exaggeration of its activity. Chronic blepharospasm will thus in time lead to a mild degree of entropion, while any affection of the inner palpebral surfaces which leads to cicatricial contraction will still more intensify it. So soon as trichiasis or irritation by the eyelashes is added to what has gone before, every feature is exaggerated and the cornea is made to lie practically in contact with the skin surface of the eyelid. A further consequence is corneal disease, often with ulceration and opacity, with even worse structural changes.
The condition is really a serious one and is to be treated not alone by operation upon the lid, but care should be given to all the contributing features. So far as the lid condition alone is concerned, I have found the operation suggested by Hotz the most satisfactory of any, at least in average cases. An incision is made from one end of the lid to the other, along the distal border of the tarsal cartilage, and down to it. Through this a bundle of those orbicularis fibers which run parallel with the incision is dissected away. In extreme cases the tarsal cartilage, which is incurved as the result of the old condition, may be either incised or a strip excised from its structure. Sutures are then inserted which include not only the borders of the skin incision, but the exposed border of the tarsus and the tarsoörbital fascia. By applying the central suture first, and then one on either side, it will usually be found that as the sutures are tightened the edge of the lid is drawn outward and the desired effect obtained.
The large number of operative methods which have been suggested for the cure of entropion bespeak the variety of causes which may produce it and the many devices to which different ingenious ophthalmic surgeons have resorted.
Fig. 390
Arlt’s operation for ectropion. (Arlt.)
This condition is the reverse of entropion, and implies eversion of the margin, or of a considerable portion of a lid, with consequent exposure of its conjunctival surface, which undergoes changes in consequence of which it becomes thickened, contracted, and irritated. Ectropion may possibly be produced by violent orbicular spasm, especially in children, the lids being so tightly shut as to be everted. Ordinarily it is the result of external lesions which produce cicatricial contraction, like burns, or of chronic ulcerative lesions along the palpebral border, such as are met with in tuberculous and syphilitic disease. The lower lid is much more frequently involved than the upper.
For the relief of ectropion plastic operations are practised, usually on the lower lid. The milder cases require a V-shaped incision, its apex downward, with free dissection of the integument up or near to the margin of the lid, by which it is released from the scar tissue which has bound it down. Fig. 390 illustrates the general principle of such an operation. The lower portion of the V-shaped defect is then brought together with sutures, the triangular flap being fastened in a position much higher than that in which it originally rested.
All of these operations upon the eyelids are included under the term blepharoplasty, of which the above is the most simple. When necessary new flaps may be raised from the temporal region, from the forehead or from the cheek, as may be required, and turned into place, their pedicles being so planned as to carry a sufficient blood supply for nourishment of the same. If this supply be properly provided these operations are practically always successful. It is necessary only to make the transplanted flap at least one-third larger than appears to be necessary, judging from mere size of the defect, for experience shows the necessity of allowing at least one-third for primary and cicatricial shrinkage. A heteroplastic operation is occasionally performed for this purpose, by which the flap of skin is detached from an entirely different part of the body, or from the body of another individual. Skin thus transplanted should be prepared by removal of all of the fat upon its raw surfaces, skin alone being desired and not other tissue. Figs. 391, 392, 393 and 394 illustrate blepharoplastic operations of various types, which may be modified or made more extensive. These are but a few of the various plastic devices, and are intended to serve merely as suggestions or examples rather than methods to which one is limited.