CHAPTER X. WHEN one eye has been destroyed by injury, the mischief in many cases does not rest there; the other eye takes on morbid action, and total blindness is the frequent result. To prevent this result has been one of the advantages derived from the employment of anæsthetics, for it has enabled us to perform fearlessly, and with perfect confidence, operations from which we formerly shrank, not so much from their danger to life, as from the severity of suffering inseparable from their performance. The term "sympathetic" or "reflex" ophthalmitis has been employed to designate the insidious inflammation which ranks amongst the most intractable of ocular diseases; and it is now known that as the disease depends on a distinct exciting cause, no remedies addressed to the eye secondarily affected avail whilst the primary exciting cause continues in force. The sympathy between the eyes, which is so familiar to us, is readily explicable when the anatomical relations in which they stand is remembered. The decussation of the fibres of the optic nerves and the direct communication established between the retina of the two eyes, by means of the interlacement in the chiasma, bring at once within our comprehension the channel by which morbid irritation is conveyed from one eye to its fellow; it is well known that if an A remarkable illustration of the effects of sympathy between the eyes is mentioned in the Lectures' of Dr. Brown-Séquard. "I know," says he, "of a WOUNDS AND INJURIES OF THE EYE. 297 eye has received injury or suffered from inflammation, the injudicious use of the sound eye speedily excites pain in the injured organ, and vice versa. So great is the influence of a diseased eye on a sound eye, that I have seen several instances in which, one eye being lost, not a gleam of light could be borne by the other eye; but when that was carefully covered, the blind eye could be examined at leisure, the light of the mid-day sun not being perceptible to it. The sympathetic influences, or reflex phenomena, are in some instances curious. In strumous ophthalmia a violent fit of sneezing is a common result of exposure of the eyes to light, the excitement of the retinæ diffusing itself to the branches of the fifth pair, supplying the Schneiderian membrane, and giving rise to the sensation of tickling in the nose, whence the sneezing. A singular case came under my notice last spring. A young lady had, from purulent ophthalmia in youth, a dense and projecting cicatrix of the left cornea; whenever she lay with her head in any other position than turned to the left, violent sneezing came on; she therefore invariably lay on her back with her head so turned. I cut away the cicatrix from the cornea, and from that time she lost all tendency to sneeze, and was able to assume any posture without inconvenience. The ordinary characteristics of sympathetic inflammation are, dimness of sight, passing with more or less rapidity into blindness, from slow disorganizing inflammation; at first the appearances are by no means indicative of the formidable most curious case of inflammation of the cornea and conjunctiva, followed by ulceration and opacity of the cornea, due to overwork with the microscope. It has occurred in a distinguished friend of mine, Dr. F., now professor at Lille. In this case anæsthesia and a degree of atrophy of the face were produced at the same time as the ophthalmia, on the left side, the micrographer making use of his right eye."-Lancet, Nov. 20th, 1858. nature of the disease; there is some sclerotic redness around the cornea, and the iris becomes discoloured; according to my experience effusion of lymph upon the capsule of the lens is an early result. Still the surgeon may fairly imagine that a mercurial course, with the local aid of belladonna, will restore the eye; unfortunately experience shows that such expectations are seldom realised; the sclerotic redness varies-sometimes nearly disappearing, at other times being considerable. The pain, too, varies, but from the commencement there is dull aching over the brow, which increases in extent and severity when there is accession of inflammation. From the commencement, alteration of colour and of form in the iris, steadily proceeds; that membrane gradually becomes dull, discoloured, often of a dingy green hue streaked with dark lines; an early condition is adhesion of the margin of the pupil to the capsule of the lens, and this gives rise to a peculiar change. This binding down of the pupil cuts off the communication between the anterior and posterior chambers, effusion takes place in the posterior chamber, and the iris being the most yielding membrane is bulged forwards in a convex form. Thus it may remain, or it may undergo a change the result of parenchymatous inflammation. The appearance is precisely that which might be expected from absorption of fibres of the true iris and the projection of pouches of uvea through the interstices. Such was supposed to be the condition by Jaeger, who called attention to it, but Klemmer asserts that the change is really a thickening of the iris in parts from lymph which is thrown out, and that the dark colour is caused by pigment which is also deposited. The pupil presents at first a faint greyish tinge from the effusion of a delicate layer of lymph, but as this increases, the whiteness becomes more marked, being spotted here and there with black pigment. Thus, disorganization too often proceeds the vitreous humour becomes fluid-the eye loses its consistence the retina its sensibility, until at length atrophy and shrinking of the globe with total blindness is the sad result. There are instances in which the attack is rapid and the symptoms of inflammation marked from the commencement. Dr. Mackenzie mentions a case in which a patient, who had suffered an injury to the right eye, incautiously read a book in small type for three or four hours in the evening; the following day the left eye showed marked iritis, even to the effusion of lymph, for the upper edge of the pupil was tagged to the capsule of the lens, and in spite of all treatment the mischief ran on to complete destruction of the eye. There is a chronic form more insidious in its character, but not less destructive than the acute form. It begins with mistiness of sight and the appearance of clouds passing before the eye, generally accompanied by musca and scintillations; the sight may even be temporarily suspended.1 The usual condition of the pupil is that of contraction, but it may be dilated and feeble in its action. As there is little visible in this stage, the danger may be easily overlooked, but when the iris becomes implicated, constituting the second stage, there is less risk of mistake. There is now dulness and discoloration of the iris; a blue iris has usually a greenish hue-a hazel or brown iris, a reddish tint. The margin of the pupil will be seen to present one or more tags of lymph binding it to the anterior capsule of the lens, and some injection of the zone around the iris will appear. The sight will be more impaired than can be accounted for by the iritic. See a valuable paper by Mr. Vose Solomon, British Medical Journal,' June 13th, 1857. symptoms, and the patient makes complaint of supra-orbital pain. The eye is now in the utmost peril, and unless the exciting cause of irritation be removed, blindness will surely follow. This blindness will be caused by the sympathetic inflammation passing into the third stage, which may present one of two forms. Either amaurosis with softening of the vitreous humour, wide dilatation of the pupil, and subsequently glaucomatous cataract; or closure of the pupil from effusion of lymph, with in some cases hardness, in others softening, of the globe. To arrive at a definite idea as to the influence of injuries in exciting sympathetic inflammation, I have searched various authorities, which with my own notes give sixty-two cases; of these the following is an analysis. Analysis of 62 cases of Sympathetic Ophthalmia. Wound from chip of metal splinter of wood fork 14 2 3 2 8 |