The principles and practice of modern surgery

by Roswell Park

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.

PANOPHTHALMITIS.

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.

Treatment.

—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.

SYMPATHETIC OPHTHALMITIS.

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.