When at rest the right eye is somewhat raised and turned outwards. Active movements outwards or downwards are restricted. There is diplopia, and the vision of the right eye is much impaired; the man can see persons, but cannot count fingers with certainty, although he sees the hand. Putting on one side the loss of free movement, there is no obvious external appearance of injury to the eye.
Mr. J. H. Fisher reported as follows:
Ophthalmoscopic examination shows the left eye and fundus to be normal. The right disc is not atrophied, but the whole of the lower half of the fundus is coated with masses of black retinal pigment. There is atrophy in spots of the capillary layer of the choroid, and the larger vessels of the deeper layer are exposed between the interstices of the pigment masses. There is no definite choroidal rupture. The lesion encroaches upon and implicates the macular region.
The injury is a concussion one, not necessarily resulting from contact, and certainly not due to a perforation. The loss of movement and faulty position are the result of injury to the muscles, and not to nerve implication.
The man complained that when he blew his nose the left eye filled with water and air came out. The left nasal duct was however shown to be intact, as water injected by the canaliculus passed freely into the nose.
Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and ecchymosis of the lids were usually well marked. The latter was sometimes extreme.
Injury to the nerves was naturally of a very mixed character. In many instances the branches of the first two divisions of the fifth nerve were obviously implicated and regional anæsthesia was common. This was often transitory when the result of vibratory concussion, contusion, or pressure from hæmorrhage. In other cases it was more prolonged as a result of actual division of the nerve. As is usually the case, when a small area of distribution only was affected, sensation was rapidly regained from vicarious sources, even when section had been complete.
As individual injuries, those to the optic nerve were the most frequently diagnosed. I am sorry to be unable to attempt a discrimination of injuries to the nerve alone from those in which both nerve and globe suffered, but the globe can rarely have escaped injury, either direct or indirect, when the bullet actually traversed the orbital cavity. (A few further remarks concerning injuries to the optic nerve will be found in Chapter IX.)
Injuries to the globe of the eye, either direct or indirect, accompanied most of the orbital wounds.
In some the lesion was of the nature of concussion. In such the bone injury was usually at the periphery of the orbit, or to the bones of the face in the neighbourhood. The loss of vision might then be temporary, persisting from two to ten days, then returning, often with some deficiencies.