Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

In cases belonging to the first group, while the sclerotic coat and cornea remain intact, the iris may be partly torn from its ciliary origin, and the blood effused collects in the lower portion of the anterior chamber; or the pupillary margin of the iris may be ruptured at several points, causing apparent dilatation of the pupil. The lens may be partly or completely dislocated, and in the latter case it may pass forward into the anterior chamber or backward into the vitreous. Among other injuries resulting from contusion of the eye may be mentioned hæmorrhage into the vitreous, rupture of the choroid, and detachment of the retina.

Injuries in which the outer coat of the eyeball is ruptured may be further subdivided into two groups according to whether or not a foreign body is lodged in the globe.

Rupture of the outer coat, especially when it results from a punctured wound, adds greatly to the risk of the injury, by opening up a path through which infective material may enter the globe, and this risk is materially increased when a foreign body is retained in the cavity of the eyeball.

When the globe is burst by a blow with a blunt object, the sclerotic usually gives way, and as the rupture takes place from within outward, there is less risk of infection than in punctured wounds. The lens may be extruded through the wound, and the iris prolapsed. If the rupture is large, the conjunctiva torn, and the globe collapsed from loss of vitreous, the eye should be removed without delay. If sight is not entirely lost and there is no marked collapse of the globe, an attempt should be made to save the eye.

Wounds produced by stabs or punctures are liable to be followed by infective complications ending in panophthalmitis. When this is threatened, removal of the eye is indicated, not only because the affected eye is destroyed beyond hope of recovery, but to avoid the risk of “sympathetic ophthalmia” affecting the other eye.

Orbital Cellulitis.—Infection of the cellular tissue of the orbit by pyogenic bacteria is specially liable to follow punctured wounds and compound fractures, if a foreign body has lodged in the orbital cavity. It may also result from the spread of a suppurative process from the globe of the eye, the conjunctiva, or the nasal fossæ or their accessory air sinuses. Both orbits may be affected simultaneously.

Clinical Features.—The disease is ushered in by rigors, high temperature, and severe pain, which radiates all over the affected side of the head. There is exophthalmos and fixation of the globe, with redness, swelling and tenderness of the eyelids, and congestion and ecchymosis of the conjunctiva. The pupil is usually dilated, the cornea becomes opaque and may ulcerate, and there is photophobia and sometimes diplopia. Suppuration usually ensues, and the pus burrows in every direction, and may ultimately point through the eyelids or conjunctiva. Sometimes the infection spreads to the meninges, and to the ophthalmic vein, and the phlebitis may then extend to the cavernous sinus. The eyeball may be infected and destructive panophthalmitis result. The prognosis therefore is always grave.

The treatment consists in making one or more incisions into the cellular tissue for the purpose of removing the pus and establishing drainage. A narrow bistoury is passed in parallel to the wall of the orbit, care being taken to avoid injuring the globe. When possible, the incision should be made through the reflection of the conjunctiva, but in some cases efficient drainage can only be established by incising through the lid. When the eye is destroyed by panophthalmitis, the propriety of eviscerating or enucleating it will have to be considered.

Tumours of the Orbit.—Tumours may originate in the orbit or may invade it by spreading from adjacent cavities. Those which originate in the orbit may be solid or cystic. Of the solid tumours the glioma and the sarcoma are the most common, and when they originate in the pigmented structures of the globe they present the characters of melanotic growths. Primary carcinoma begins in the lachrymal gland. Osteoma—usually the ivory variety—may originate in the wall of the orbit, or may spread from the adjacent sinuses.

Clinical Features.—In children, the tumour is usually a glioma, and it is frequently bilateral. It generally occurs before the age of four, is associated with increased intra-ocular tension, protrusion of the eyeball, and dilatation of the pupil, and soon produces blindness. The tumour fungates and bleeds, and rapidly invades adjacent structures and spreads along the optic nerve to the brain. It is highly malignant, and recurrence usually takes place, even when the tumour is removed early.