Treatment.
—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.
ENUCLEATION OF THE GLOBE OF THE EYE.
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.