Enucleation of the Eye.- In this operation a pair of curved blunt pointed scissors, speculum, fixation forceps and a squint hook are necessary. An anaesthetic should always be used unless some general condition renders it dangerous. The conjunctiva is to be separated from the globe close to the cornea all around, and the capsule of Tenon dissected back. Then the superior rectus muscle is taken up on the squint hook and several close to the globe the other recti muscles may be divided as most convenient and it is my practice to pick up and severe the obliques before cutting the optic nerve. Many operators however prefer to extrude the eye from the orbit by pressing between it and the orbital rim, then dividing the nerve and oblique muscles after ward. To divided the optic nerve the scissors should be inserted closed at the inner side and pushed back until coming in contact with it, when the blades are opened and the nerve severed. The eye should then be pushed forward with the scissors and the numerous small bands of adhesion, which are usually found cut away. Immediately after cutting the nerve more or less haemorrhage is apt to occur, but usually is readily controlled, after which a through irrigation of the cavity with a 1-5000 solution of corrosive sublimate should be employed and firm tight compress bandage applied.
Evisceration or Exenteration of the eye, as removal of its contents is called, is done by excising the cornea at the limbus and removing the entire contents of the globe down to the sclerotic, either with a spatula, or as performed by the late Dr. Liebold with balls of picked lint, wiping out the vitreous retina and choroid until perfectly clean. The cavity is thoroughly irrigated with a 1-5000 bi-chloride solution and the scleral wound drawn together with sutures. This operation has been highly commended of late years by Alfred Graefe, Bunge and others as a substitute for enucleation, but to Liebold should belong the credit of having first practiced it. The principal value of this operation over enucleation is that it leaves a larger and better stump for the wearing of an artificial.
Artificial Eyes are made of both glass and celluloid and are or various sizes and colors. The eye should not be worm until from six to eight weeks after the removal of the globe and then not worm continuously at first and always should be removed at night. The insertion of an eye is very easy and readily acquired by the patient. It is to be pushed beneath the upper lid and held there while the lower lid is brought over its edge. In its removal the lower lid is depressed and a probe inserted beneath the eye, which is brought forward and slips out from its own weight.
Keratoconus (Cornea Conica, Staphyloma Pellucidum).- Conical cornea is easily overlooked when but slight. In a marked case we notice that the centre of the cornea appears unusually bright and glistening as though from a tear drop but from a side view a decided prominence is at once seen. The conicity is usually in the centre but may be found at the margin of the cornea. On examination with the ophthalmoscope by the direct method there is seen a central bright red spot surrounding which is a dark zone, and again outside of this a red ring. The dark zone is due to a diffusion and reflection of the light at the base of the cone. The vessels of the fundus appear distorted and broken and the optic disc seems elongated-due to irregular refraction. The vision is often greatly impaired, even in the slightest cases, owing to the eye having become myopic from lengthening of the anterior-posterior axis and from the astigmatism caused by the irregular curvature of the cornea. This astigmatism is too irregular to be corrected with glasses. The bulging is due to a thinning or diminution in the power of resistance of the cornea. It is non-inflammatory and probably results from atrophy or some degenerative change in the corneal tissue, especially at its centre, so that it yields to the normal intra-ocular tension. Tweedy Trans. Ophthal. Soc. Un. K., Vol. Xii, p.67. believes that there may be some congenital weakness of the centre of the cornea. The condition usually commences between the ages of ten and thirty generally attacks both eyes and is most often found in delicate people. It course is very slow and may become stationary at any point. Often the apex of the conical cornea is more or less opaque.
TREATMENT.- Glasses, either spherical or cylindrical, will usually give but little improvement although, when they do they should be used. Stenopaic aperture or slit may sometimes be added with some further improvement in the vision. Operations of various kinds have been tried with more or less success when there is a central opacity of the cone, an iridectomy will often be of value. Despagnet Soc. d. Opht. de Paris, November 4, 1890. recommends the excision of a crescentic bit of the cornea. The use of the galvano-cautery has been tried in numerous cases and will benefit in some. We have seen a case treated by Dr. Knapp with decided flattening of the conicity and some improvement of vision. He applies an electrode of about the size of the head of a pin to the apex of the cone and burns away a portion of the external surface of the cornea. Under antiseptic dressings there is but little reaction and the resulting opacity is but slight.
The progress of conical cornea can often be checked by the employment of the proper homoeopathic remedy though it is impossible to diminish the conicity of the cornea without instrumental interference.
The remedy must be chosen according to both local and constitutional symptoms, though Calc iod., Eserine and Pulsat, have thus far proved most serviceable. Suitable hygienic measures are of great importance, as this affection may be dependent upon a debilitated condition of the health. A pressure bandage may sometimes be used with advantage.
Keratoglobus (Hydrops of the Anterior Chamber, Globular Cornea). In this disease there is a general spherical distension of the cornea in all its diameters. The sclerotic is often involved in the same process. Sometimes the protrusion becomes so great as to extend between the lids, which cannot close over it, giving a peculiarly starting appearance to the eye (buphthalmos). In buphthalmos the cornea may either remain transparent or become opaque. The sclera is thinned and of a bluish tint, due to the shining through of the choroid. The anterior chamber increases in depth and circumference and the aqueous remains clear. The iris is enlarged, stretched and somewhat tremulous from lack of support the pupil is dilated and sluggish. The iris may be bulged forward or cupped back. Vision is usually greatly impaired. The disease is fortunately quite rare and its treatment of but little value. The use of Eserine and the compress bandage in the early stages may somewhat tend to check its progress. Iridectomy may also be of some value, and in advanced cases, the operations for staphyloma may be needed.
Injuries of the Cornea from Foreign Bodies, such as chips of iron, steel, wood, glass, etc., are of very frequent occurrence. When imbedded in the cornea they generally excite considerable reaction-the eye becomes red and painful, there is photophobia and lachrymation and the pupil may be somewhat contracted. They are as a rule readily seen, but in some cases of very small particles it is with difficulty that they can be recognized even with the use of an oblique illumination and of atropine to give a dark background. They may set up an inflammation of the cornea or even the iris and in old, enfeebled subjects, may result in considerable ulceration or slough of the cornea. Again they may cause no irritation. Knapp reports a piece of steel imbedded in the cornea for two year without causing any irritation.
TREATMENT.- Foreign bodies in the cornea can usually be easily removed after the instillation of cocaine by the aid of a gouge without fixation of the eye, though if the patient be very nervous and the foreign body be deeply imbedded in the cornea it is better to use a stop speculum and fix the eye with a pair of forceps or employ an anaesthetic. If the foreign body has penetrated the cornea and lies partly in the anterior chamber, a broad needle should be introduced behind it in order to prevent its being pushed backward in the attempt to extract it. Pieces of steel may often be removed with a magnet. After the removal, if much inflammation, use Acon and cold compresses.
Injuries from Lime and Chemical Agents are apt to cause more or less extensive sloughing of the cornea. The conjunctiva is usually affected, together with the cornea and their treatment has already been referred to under the conjunctiva.
Wounds of the Cornea.- Small clean cuts or perforations usually soon heal, with no trace of the injury remaining. The chief danger of penetrating wounds of the cornea is from injury or prolapse of the iris, or from injury to the lens, and from either of these accidents lead to a general inflammation of the whole eye (panophthalmitis). Bruises are very apt to excite suppuration.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.