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ON SYMPATHETIC OPHTHALMIA, WITH ANALYSIS OF FOURTEEN CASES TREATED BY ENUCLEATION.
BY MR. W. SPENCER WATSON, F.R.C.S.
Surgeon to the Royal South London Ophthalmic Hospital.
Ir has now become an accepted rule, perhaps almost an axiom in ophthalmology, that whenever an injured or diseased eye appears to be causing sympathetic ophthalmia it should be forthwith removed. Some surgeons even go so far as to advise removal of an eye under some circumstances before sympathetic irritation has shown itself, but where it is almost certain that the disease will sooner or later be induced. For instance, an injured eye in which a foreign body is known to be lodged is a source of constant danger to its fellow; and it is urged by some surgeons that, in all cases in which it is impossible or inexpedient to attempt the removal of the foreign body, the eyeball itself should be removed. Again, in cases of total destruction of sight after an attack of glaucoma or purulent ophthalmia, if remains tender or painful, or both, it is probably better to extirpate the diseased and useless organ before sympathetic irritation of its fellow has commenced. And the reason of this is sufficiently obvious. Prevention is better than cure. Sympathetic ophthalmia once started is a most intractable malady
and cannot always be arrested by the enucleation of the fellow eye, even when this remedy is followed by most energetic local and constitutional treatment.
Hence it may be laid down as a rule of surgery to enucleate an injured or diseased eyeball whenever sympathetic ophthalmia is present or may be anticipated. But the discretion of the surgeon will decide in each particular case how far he is justified in the anticipation of a future sympathetic ophthalmia. Several of the cases in the Table (especially Cases 2, 3, 6, 7, and 10) illustrate the danger of delay, at the same time that they also show the possibility of a long period of immunity from the anticipated danger. "If," a patient might argue, "my eye will last me twenty-five or even twenty-eight years (as in Cases 2, 3, and 10), I may as well avoid the severe operation of enucleation as long as possible, and submit to it at last, when I find the sight of my sound eye failing." There are, however, several fallacies in such a train of reasoning.
(1.) The operation of enucleation is not a severe one, under the anaesthetics now employed, and is never followed by any serious results.
(2.) The longer the operation is delayed, the greater will be the danger of uncontrollable cyclitis being set up. At any time the general health might become temporarily impaired, and the chances of cyclitis coming on would be much increased. It is noteworthy that in the three cases in which the disease had been of longest continuance, bony deposits were formed. It is probable that these deposits in the course of growth would be additional sources of irritation, acting like foreign bodies on the ciliary nerves. Hence an operation undertaken before time had been allowed for the deposition of bone in the choroid would be more likely to prevent mischief than if they had long been deposited, and had slowly but persistently irritated the eye and its fellow.
(3.) It is observable that in two of the cases operated on twenty-five years after the injury, the sight was only partially restored, in both the field of vision being much contracted. In Case 7 the operation barely saved the sight, and only after a
1 Bonnet's operation was employed in all the cases in the Table, and is the one universally adopted by surgeons in the present day.
long course of mercury and iodide of potassium; and in Case 14 the recovery of sight was very slow, and only very imperfect. In both these cases years had elapsed since the primary mischief, but it came at last, and was then very severe and intractable. Hence an early operation is always preferable to delay, and as no harm can result from a too early interference, it is a rule to operate even when in doubt as to its absolute necessity.
It sometimes happens that the injured or diseased eye retains some amount of, or even good, vision, and here of course delay is most tempting. I myself would never advise enucleation for prevention of sympathetic cyclitis in a case in which there was really useful vision in the injured or diseased eye. If, however, the sight were so far lost as to be useless, the case would be the same as that of a blind eye.
When, however, sympathetic irritation, as evidenced by intolerance of light, fatigue in reading, lacrymation, impaired vision, aching, &c., had once commenced, it would be justifiable, I think, to enucleate an eye with even a considerable amount of useful vision. Nevertheless it would under such circumstances be desirable first to attempt treatment for the improvement of the general health, at the same time keeping both eyes shaded strictly from light, and giving them absolute rest. If, after a fortnight or three or four weeks of such treatment, no improvement occurred, the operation of enucleation should be resorted to, though possibly in such a case division of the ciliary nerves by Meyer's method might first be tried, leaving the more formidable proceeding as a dernier ressort. I have only tried Meyer's operation in one case (Case 1), and it certainly promised well at first, though ultimately enucleation was required from a recurrence of the symptoms. It can only be applicable to a very small number of cases, those, viz., in which the irritating influences are confined to a certain quadrant or other small arc of the ciliary region. In the majority of cases the congestion and tenderness of the ciliary region extends around the entire circle, and it would be obviously impossible to divide all the ciliary nerves without at the same time performing abscission, an operation entirely unsuited for the cases under present consideration.
The state of general health often seems to have a decided influence in determining the outburst of sympathetic cyclitis. In Case 2 the patient was intemperate and out of condition; in Case 11 the health was broken by syphilis; and in Case 14 the health was very feeble, the man's complexion being pallid and flabby, his temper extremely peevish, and his manner anxious and nervous.
In all these three cases (and I think in others in which the circumstance was not noted) the injury had been almost forgotten until the outburst of cyclitis, determined by the lower state of general nutrition at the time.
The use of mercury after enucleation was well illustrated by Case 7. No immediate benefit resulted from the operation, partly no doubt in consequence of the obstruction to vision by the synechiæ and effused products in the deeper structures, and partly from the persistence of the morbid action. The removal of these products and the arrest of the cyclitis could only be due to the mercury and iodide of potassium, though the enuclea tion was quite necessary as a preparation for this treatment.
In Case 14 opiates were of great service in allaying the irritability and restlessness due to long-continued pain and anxiety. I have often found some form of opium extremely useful in similar cases, and if from any cause it is necessary to delay operating, when it is clear that the operation will be ultimately required, the use of opiates at night gives great temporary relief to the patient, and should be persisted in for some time after the operation, in conjunction with other treatment directed against any constitutional dyscrasia that may be present. If, however, the restlessness is found to depend, not upon pain, but upon nervous irritation and exhaustion, chloral hydrate answers extremely well, and does not give rise to the disturbance of the digestive organs and bowels that often follows the use of opium.
Whenever there has been decided cyclitis in the uninjured eye, it is better to defer the fitting of an artificial eye till this has subsided. Otherwise, the sooner an artificial eye is applied the better will be the cosmetic effect. The longer it is delayed the more the eyelids shrink and fall in upon the orbit; and when this shrinking has gone on to any extent, it is impossible
for the patient to wear a full-sized eye. The consequence is, that the small size of the artificial eye as compared with the sound eye at once attracts attention and is very unsightly. But this is a matter of secondary consideration as compared with the preservation of the sight of the uninjured eye, and the cosmetic effect must be sacrificed if it seems at all possible that wearing an artificial eye is irritating or likely to keep up sympathetic cyclitis.
In considering the advisability of removing an eye in which a foreign body is known to be present, it is well to remember that foreign bodies have been removed without resorting to enucleation, and without any ill results following to the uninjured eye. Thus Mr. Dixon was fortunate enough to remove a chip of metal from the vitreous, having previously discovered it by ophthalmoscopic examination.1 And several instances are on record of the successful removal of foreign bodies lying on the iris and in the substance of the lens. The following case occurred in my own practice. A man received part of the charge of a gun loaded with small shot in his eye. Sight was at once destroyed. He was sent to me by Mr. Ireland, who at first attended him, and from the appearance of the eyeball and the position of the wound in the sclerotic, it was evident that a shot had lodged itself in the vitreous or close to the vitreous in the ciliary region. The shot could not be seen by the ophthalmoscope, but effused blood was seen lying at the lower part of the vitreous space behind the iris. Wishing, if possible, to avoid enucleation, but at the same time preparing the patient for the possible necessity of enucleating, I at first made a large iridectomy downwards, in the expectation that the large pupil thus obtained would give a more perfect view of the vitreous chamber, and perhaps allow of a subsequent operation for the removal of the foreign body. While in the act of making the first incision, the shot rolled out into the oculo-palpebral fold, and thus solved the difficulty. The patient made a good recovery, the eye, of course, remaining blind and with a displaced pupil ; and no sympathetic irritation had shown itself in the fellow eye. Two years after the accident, the sight of the uninjured eye was as good as ever.
1 See Ophthalmic Hospital Reports, vol. i. p. 80.