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Panophthalmitis—Fatal Meningitis Following Enucleation of When Opera- ¡Degrees of Rotation

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Panophthalmitis—Fatal Meningitis Following Enucleation of When Opera- ¡Degrees of Rotation to the left as he could and again measured by the If I sum up all the clinical facts, I should say light reflex on its cornea the position of the glass evisceration has nothing to show in its favor, while eye. As the artificial eye follows as well as it can it compares decidedly unfavorably with enucleation the rotations of the natural eye, I believe these meas¬ in the frequent violent reaction and slow recovery, urements thus obtained represent the extreme limits and therefore does not deserve to take the place of of motion the artificial eye was capable of in every enucleation. case. The results of my tests are given in the fol¬ lowing instructive table : FERIMETEIC MEASUREMENTS OP THE LATERAL MOVEMENTS OF ARTIFICIAL EYES. PANOPHTHALMITIS—FATAL MENINGITIS FOLLOWING ENUCLEATION OF WHEN OPERA- ¡DEGREES OF ROTATION. PATIENT'S AGE. TION WAS PER- I- THE EYE. FORMED. INWARD. OUTWARD. Read in the Section on Ophthalmology at the Forty-fourth Annual L. S.,. 45 Enucleation . 10 yeai s ago. 15 25 Meeting of the American Medical Association. F. 21 Evisceration. 3 months - S., . ago. 20 . 21 1 15 15 BY A.C.,.. Enucleation year ago. S. D. RISLEY, M.D. Mrs. 4 months 15 25 M., . ago. ATTENDING SURGEON AT THE WILLS EYE LECTURER ON OPH¬ Mrs. .30|Evisceration months 20 25 HOSPITAL; E., . .50¡Enucleation a% ago.¡ THALMOLOGY IN THE UNIVERSITY OF PENNSYLVANIA ; PROFESSOR G. 24¡Enucleation 1 month 20 L., . ago. OF OPHTHALMOLOGY' IN THE PHILADELPHIA POLICLINIC M. 20 10 J.,.42¡Atrophic. Eye. years ago. 15 AND COLLEGE FOR GRADUATES IN MEDICINE, L. H.,. 22 Enucleation 6 weeks ago. 15 20 Mrs. 10 15 PHILADELPHIA. L.,.20|Atrophic. Eye. years ago. John M., age 47, but appearing at least 67, presented him¬ These measurements show there is absolutely no self at the Wills Eye Hospital Dec. 12, 1892, bearing a letter difference in the extent of the lateral movements of from his physician, Dr. 1). T. Laini of Media, Penn., under whose care he has been for a severe attack of iritis in the the worn on an evisceration and glass eye, stump, left eye. The disease proving rebellious, he was advised to worn on an in case that enucleation stump ; either seek hospital treatment. He was in feeble health, suffering the inward movements (adduction) varied between from severe pain in the eyeball and with violent left hemi- 15 and 20 degrees and the outward movements (ab¬ crania; vision was reduced to quantitative perception of between 15 and 25 These results light. There was deep ciliary injection, small pupil, slight duction) degrees. haze of the cornea and the remnant of a blood clot was still were not surprising to me ; for though I have heard lying in the lower angle of the anterior chamber. There so much about the larger, better stumps gained by were numerous posterior synechia and dilated blood vessels evisceration I have found these stumps shrink could be seen coursing over the surface of the iris. Ten¬ sion was normal the anterior chamber shallow. He was so much that three months after the but away operations placed in bed, blood extracted from the left temple and no of what we there is more them left than find after calomel and soda purge given, eserin being instilled locally. a suppuration of the globe, and that it is difficult to He experienced very prompt relief and one week later tell by the stump whether enucleation or eviscera¬ vision was somewhat improved, the blood clot absorbed, and tion has been This observation I have the ciliary injection less marked but no view of the fundus performed. could be obtained. There was simply a gray-red reflex from made not in own but also in only my .cases eyes the pupil. "When-seen two days later, there was a fresh red which had been eviscerated by other surgeons. blood clot lying in the pupil and on the upper and inner But even granting a larger permanent stump to the pupillary rim of the iris and a large blood vessel could be seen it was I still maintain the artificial eye does entering from which the blood apparently issuing. evisceration, As yet there was no pain, but the hemorrhage was soon fol¬ not gain any material advantage by it. The largest lowed by decided increase of tension and the ball became and iDest movable stumps, superior to any furnished tender to pressure and with it his headache returned. He by evisceration, undoubtedly are those slightly lost appetite, became sleepless and the general health with well but rapidly declined. Under a careful regimen, however, the atrophie eyeballs preserved vitreous, health the blood clot once more absorbed and loss of the cornea and iris the result of improved, complete (as the eye became quiet but showed a tendency to frequent sloughing or surgical operation). Glass eyes can be recurrences of increased tension and ciliary redness. Dur¬ worn over such but do not ing one of the intervals of freedom from acute symptoms a atrophie globes, they iris show In my table there are broad iridectomy was made upward. The was found any superior mobility. friable ; the operation was smooth and successful, but bleed¬ two such cases and we see that the one shows an ; ing was profuse and the eye was bandaged with the an¬ unusually limited movement; and the other (the terior chamber filled with blood. There was no undue last in the list) shows no better adduction (15 degrees ) reaction and the blood clot slowly absorbed, but the wound In a than we get by enucleation or evisceration cases and refused to heal. ten days there was pouting black best 5 mass lying in the wound, but slightly elevated above the exceeds their abduction by degrees only. corneal limbus, and occupying the entire line of incision. These atrophie eyeballs had an excellent rangé of The operation was done under antiseptic precaution and lateral rotation ; and if the artificial eye could be the eye was subsequently kept bandaged, being thoroughly the it washed with bichlorid solution at each dressing and dusted ___cfij»ented onto atropic globe would, of course, of follow the rotations of the and the cosmetic with iodoform. There were no visible signs suppuration latter, but his health steadily failed, his hands were hot and there effect would be perfect, because the artificial cornea was a hectic flush on his ckeeks, but only slight if any rise would describe lateral rotations as perfectly as the in his temperature. The eyeball was soft ; there was no of no was natural cornea. But as the artificial is not fas¬ dread light and pain or headache. He greatly eye in was to tened to latter does not depressed spirts, felt that he going die and begged the stump, the impart its to allowed to return to his home. The was then the be eye motions to the super-imposed glass shell and enucleated on Jan. 25. 1893, and found filled with pus. The axis of rotation of the glass eye lies much in front of nerve was severed well back, the orbit thoroughly drenched with the When, therefore, the eye seems to with bichlorid of mercury solution, well dusted iodo¬ stump. glass form and for twelve hours. He made a rapid and turn to the or its cornea shows little bandaged right left, very favorable recovery without suppuration of the stump. The real lateral movement, its principal motion being a infiltration of the tissues of the orbit absorbed rather more rotation on its vertical axis so that its center faces slowly than usual but his health rapidly improved so that he to the or left. On this account the movements on the fourteenth day, February 7, was discharged from right the with no of an artificial will be confined to narrow hospital apparently well, certainly symptoms eye always to awaken apprehension regarding his future. One week limits, whether the glass shell be inserted after enu¬ later, February 15, twenty-one days after the excision of the cleation or evisceration. eyeball, he sent for his physician, Dr. Lainé, but in his absence Downloaded From: by a University of Missouri - Columbia User on 01/06/2018 was seen by Dr. J. H. Fronfield, to whom I am indebted for fatal meningitis was infectious and that it was set the following history: He complained only of weakness up germs the cut tissues and and for the was normal and by conveyed through disgust food, temperature vessels the membranes and ven¬ throughout the subsequent history, remained either normal open in the orbit to or sub-normal; although taken twice daily at no time was ous sinuses of the brain. It would be a comforting there any rise. There was at this time some suppuration of view of the case could we feel assured that the first the stump, he was anemic, the tongue pale, large, flabby proposition was a correct solution of the unfortunate and indented. He was not considered seriously ill. Calomel and soda were to move the bowels and he received sequel. prescribed between elixir of iron, quinin and strychnia as a tonic. The very close relation that exists the eye¬ February 18, 10 a.m. Bowels have been freely moved but ball and the intracranial mass would lead us to antici¬ can not take the tonic. Urine free from albumen. 7 p.m. pate serious to life from its excision. Such weaker is sure he will die. danger Decidedly ; very melancholy ; would moreover be No pain in the eye ; pupil reacts promptly.
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