386
WORRELL: Spontaneous Expulsion of
SPONTANEOUS EXPULSION OF FOREIGN BODY FROM ANTERIOR CHAMBER. By J. P. WORRELL, M.D., TERRE HAUTE, IND.
Master L., aged I5, two weeks previous to his first visit to my office, received an injury of the right eye while exploding a guncap by striking it with a hammer. His sight was impaired at once, and the eye became red, with, however, but little pain. His physician reports the appearance of pus in the anterior chamber at the end of a week, though probably this was a deposit of lymph. The treatment had been some simple wash. The boy was brought to my office on the 6th of January, I883, when the following conditions were found: Sclera deeply engorged, being almost livid in color; cornea hazy throughout, preventing any view of the iris. The lower half of the cornea was entirely opaque and bulging. Tn. The pain was slight, with occasional exacerbations. Perception of light and projection good. Ordered atropia and compressed bandage. Under this treatment the eye in a few days became entirely painless. Scleral engorgement lessened, and clearing of the cornea proceeded to a degree permitting a comparatively satisfactory view of the upper part of the iris, which appeared to be healthy. Pupil was moderately dilated, central portion of it being occupied by a small deposit of lymph. The lower portion of cornea, involving its lower and nasal half, is still cloudy; the bulging previously mentioned unchanged. Across it run a few small vessels from the adjacent corneal margin. Upon its surface, IA mm. in length and very close to the limbus, was seen a fine horizontal linear cicatrix. Behind this portion of the cornea as distinctly seen an ovoid body, yellowish in color, with apparently well-defined outlines, its position not undergoing any change in alteration of the position of the eye. That portion of ciliary region corresponding to the position of the yellowish mass con-
Foreign Body from Anterior Chamber.
387
tinued to be deeply engorged. Other portions of the sclera becoming pale and nearly normal in appearance. Absolute freedom from pain; no tenderness on pressure. On the 13th of same month, my notes state that under the continued use of atropia and compress bandage the cornea had cleared up until there remained but a slight diffuse opacity in the lower and inner quadrant. In consequence of the bulging at this point, the anterior chamber was very deep. There was now distinctly seen an oval yellowish colored mass 4 mm. in length, lying in the bottom of the chamber and rising about 24 mm. towards the pupillary border. The pupil was still dilated upwards, circular in shape, except that at the lower and inner portion was a notch due to rupture of the circular fibers. Behind the notch, extending nearly to the center of capsule, a sharply-defined line, appearing black when seen with the ophthalmoscope, and gray by lateral illumination, due to a slight rupture of the capsule, was seen. In its neighborhood a faint lenticular opacity was recognized. The sight much improved and fundus readily illuminated. On the i6th of February the conditions had much improved. Ciliary injection had disappeared save in the neighborhood of the yellowish mass. The cornea had cleared up, showing on its inner surface, or in the innermost layers near the limbus, a dark point apparently from the infiltration of pigment. Just above this point under examination by oblique light, there came distinctly into view a bright reflecting surface, the metallic nature of which could not be mistaken, nearly square in outline, being Ii mm. in length. This could also be seen by ordinary daylight, the cornea being sufficiently clear to permit a clear view of the body. It lay in a plane nearly vertical, its upper edge leaning backwards about I50 from the vertical, and being at an angle of about 400 to the surfaces of the cornea. Its lower margin was engaged in the innermost layers of the cornea, the transparent tissue of which permitted an easy examination. Operation for removal of the foreign body had been suggested at various earlier times, but I now recommended its extraction
388
WORRELL: Spontaneous Fxpulsion of
with some importunity. This, however, was declined. Vexed that so obvious a course should be refused, I doubtless manifested my impatience and expressed a wish that the patient assume, thereafter, the responsibility of the case. I did not see it again until the 24th of the same month. The eve was then quiet. Diligent search failed to discover any sign of the foreign body. The yellowish mass in the anterior chamber had also disappeared, so that I was able to look down into the bottom of the chamber to the utmost limit of the iris. The patient stated that the day before something had scratched the eye " right smart." He said he had rubbed the eye vigorously, after wv,hich the irritation ceased. At this time the eye was so quiet it seemed the case had reached its termination. No indication existed for further treatment. However, I requested him to call occasionally and report. On the 5th of March, nine days later, he came to the office exulting in the possession of the foreign body. He said that the day previous, feeling. something scratching the eye, he rubbed it with a pledget of cotton, thereby removing the point of irritation to the inner canthus. Removing some secretion whlIich had gathered there, he found in its midst a small piece of bright copper, which I at once recognized as the foreign body that I had seen in the anterior chamber. This was found to be a flat piece of copper of the thickness of writing paper, about I4 mnm. in length, rather rough in fracture, one edge slightly turned up. The eye was quiet and presented the following appearance: No ciliary injection. In the lower-inner quadrant this membrane presented a slightly increased curvature, which portion was traversed by a crescentic nebula having its extremities at the limbus and surrounding the dark area where the pigment had infiltrated the cornea tissue. From a point in the horizontal margin of the anterior capsule, just to the nasal side of the center of the pupil, there is seen a white band which runs downward and forward, reaching and becoming adherent to the cornea at the position of the black area described. To this band the torn edges of the iris became adherent, drawing that portion of the iris forward, thus encroaching upon the depth of the anterior chamber.
Foreig;z Body from Anterior Chamber.
389
A few days later, when the effects of the mydriatic had passed off, the pupil became eccentric, so that the upper end of the white band reached the upper margin of the pupil, dividing that space into two unequal portions. Sight was 15/XL. This case I believe to be quite unique in that it is one of spontaneous expulsion from the anterior chamber of the eye of a foreign body which had passed entirely through the cornea and was freely movable within the anterior chamber, and also unique in its expulsion without ulceration or other destructive change. That it must have passed entirely through the cornea and become freed from that tissue is evident by a comparison of the minute size of the offending body and the distance from the point of entrance to the point of injury in the iris, this being in a vertical direction at least 5 mm. Assuming, as was probably the case, that the aqueous humor had not been lost, the distance between the point of entrance and the point of injury to the capsule must have been considerably increased. It is probable, therefore, that the foreign body was driven entirely through the cornea, traversed the anterior chamber, cut the sphincter of the iris, lacerated the anterior capsule, after which it had fallen into the anterior chamber, where it had become surrounded by a mass of lymph; that the lymph had been ultimately absorbed and that the foreign body had made its way - whether at the exact point of entrance or not it is impossible to say -by absorption of the tissue in front of it, through the cornea - finally escaping unassisted from the eye. From the limited opportunities which I have had of consulting our literature, I have been unable to find any report of a similar case. Norris and Oliver mention that " very minute foreign bodies are sometimes spontaneously extruded from the eye," this taking place during attacks of inflammation when the minute body lacerates through its point of entrance. In most all of the cases referred to the inflammation was destructive and fatal to the eye. Since writing the above my attention has been called to a case of " spontaneous extrusion through the original point of entrance in the corneal membrane," in a report by Dr. Oliver, OPH.- IO
390
HARLAN: Delayed Union after Cataract Extraction.
published in the Annals of Ophthalmology for April, which presents more points of similarity to the case which I report than any other I have found. DISCUSSION.
DR. H. F. HANSELL. - About three years ago I reported a case similar in some respects to Dr. Worrell's, in which a piece of steel which had been in the an,terior chamber, according to the patient's story, for fifteen years, spontaneously extruded through the cornea. The wound of entrance was invisible. The steel gradually opened a way for itself through the cornea, and more than half of it was exposed when I saw it, so that I simply helped it out with a pair of forceps.
DELAYED UNION AFTER CATARACT EXTRACTION. BY GEO. C. HARLAN, M.D., PHILADELPHIA, PENN.
So far as I have been able to learn, there are no statistics to indicate how long the wound may remain open after extraction without necessitating a grave or hopeless prognosis of the final result. The text-books generally do not refer to the subject, and tabular reports of operations give no definite data. As some of my friends, as well as myself, have looked in vain for comfort when the anterior chamber has remained empty after the first few days, I have thought it might be worth while to bring the subject before the society. A few months ago I operated on a lady eighty-three years of age. She was in fair health, neither diabetic nor albuminuric, but too feeble to take a journey, and the operation was performed at her distant home, but she was left in charge of a good general surgeon and an experienced trained nurse. The operation was entirely smooth, there was no prolapse of the iris, and the pupil remained round and central. The usual compress and bandage were used, and after the second day the eye was carefully douched
WORRELL: Spontaneous Expulsion of
SPONTANEOUS EXPULSION OF FOREIGN BODY FROM ANTERIOR CHAMBER. By J. P. WORRELL, M.D., TERRE HAUTE, IND.
Master L., aged I5, two weeks previous to his first visit to my office, received an injury of the right eye while exploding a guncap by striking it with a hammer. His sight was impaired at once, and the eye became red, with, however, but little pain. His physician reports the appearance of pus in the anterior chamber at the end of a week, though probably this was a deposit of lymph. The treatment had been some simple wash. The boy was brought to my office on the 6th of January, I883, when the following conditions were found: Sclera deeply engorged, being almost livid in color; cornea hazy throughout, preventing any view of the iris. The lower half of the cornea was entirely opaque and bulging. Tn. The pain was slight, with occasional exacerbations. Perception of light and projection good. Ordered atropia and compressed bandage. Under this treatment the eye in a few days became entirely painless. Scleral engorgement lessened, and clearing of the cornea proceeded to a degree permitting a comparatively satisfactory view of the upper part of the iris, which appeared to be healthy. Pupil was moderately dilated, central portion of it being occupied by a small deposit of lymph. The lower portion of cornea, involving its lower and nasal half, is still cloudy; the bulging previously mentioned unchanged. Across it run a few small vessels from the adjacent corneal margin. Upon its surface, IA mm. in length and very close to the limbus, was seen a fine horizontal linear cicatrix. Behind this portion of the cornea as distinctly seen an ovoid body, yellowish in color, with apparently well-defined outlines, its position not undergoing any change in alteration of the position of the eye. That portion of ciliary region corresponding to the position of the yellowish mass con-
Foreign Body from Anterior Chamber.
387
tinued to be deeply engorged. Other portions of the sclera becoming pale and nearly normal in appearance. Absolute freedom from pain; no tenderness on pressure. On the 13th of same month, my notes state that under the continued use of atropia and compress bandage the cornea had cleared up until there remained but a slight diffuse opacity in the lower and inner quadrant. In consequence of the bulging at this point, the anterior chamber was very deep. There was now distinctly seen an oval yellowish colored mass 4 mm. in length, lying in the bottom of the chamber and rising about 24 mm. towards the pupillary border. The pupil was still dilated upwards, circular in shape, except that at the lower and inner portion was a notch due to rupture of the circular fibers. Behind the notch, extending nearly to the center of capsule, a sharply-defined line, appearing black when seen with the ophthalmoscope, and gray by lateral illumination, due to a slight rupture of the capsule, was seen. In its neighborhood a faint lenticular opacity was recognized. The sight much improved and fundus readily illuminated. On the i6th of February the conditions had much improved. Ciliary injection had disappeared save in the neighborhood of the yellowish mass. The cornea had cleared up, showing on its inner surface, or in the innermost layers near the limbus, a dark point apparently from the infiltration of pigment. Just above this point under examination by oblique light, there came distinctly into view a bright reflecting surface, the metallic nature of which could not be mistaken, nearly square in outline, being Ii mm. in length. This could also be seen by ordinary daylight, the cornea being sufficiently clear to permit a clear view of the body. It lay in a plane nearly vertical, its upper edge leaning backwards about I50 from the vertical, and being at an angle of about 400 to the surfaces of the cornea. Its lower margin was engaged in the innermost layers of the cornea, the transparent tissue of which permitted an easy examination. Operation for removal of the foreign body had been suggested at various earlier times, but I now recommended its extraction
388
WORRELL: Spontaneous Fxpulsion of
with some importunity. This, however, was declined. Vexed that so obvious a course should be refused, I doubtless manifested my impatience and expressed a wish that the patient assume, thereafter, the responsibility of the case. I did not see it again until the 24th of the same month. The eve was then quiet. Diligent search failed to discover any sign of the foreign body. The yellowish mass in the anterior chamber had also disappeared, so that I was able to look down into the bottom of the chamber to the utmost limit of the iris. The patient stated that the day before something had scratched the eye " right smart." He said he had rubbed the eye vigorously, after wv,hich the irritation ceased. At this time the eye was so quiet it seemed the case had reached its termination. No indication existed for further treatment. However, I requested him to call occasionally and report. On the 5th of March, nine days later, he came to the office exulting in the possession of the foreign body. He said that the day previous, feeling. something scratching the eye, he rubbed it with a pledget of cotton, thereby removing the point of irritation to the inner canthus. Removing some secretion whlIich had gathered there, he found in its midst a small piece of bright copper, which I at once recognized as the foreign body that I had seen in the anterior chamber. This was found to be a flat piece of copper of the thickness of writing paper, about I4 mnm. in length, rather rough in fracture, one edge slightly turned up. The eye was quiet and presented the following appearance: No ciliary injection. In the lower-inner quadrant this membrane presented a slightly increased curvature, which portion was traversed by a crescentic nebula having its extremities at the limbus and surrounding the dark area where the pigment had infiltrated the cornea tissue. From a point in the horizontal margin of the anterior capsule, just to the nasal side of the center of the pupil, there is seen a white band which runs downward and forward, reaching and becoming adherent to the cornea at the position of the black area described. To this band the torn edges of the iris became adherent, drawing that portion of the iris forward, thus encroaching upon the depth of the anterior chamber.
Foreig;z Body from Anterior Chamber.
389
A few days later, when the effects of the mydriatic had passed off, the pupil became eccentric, so that the upper end of the white band reached the upper margin of the pupil, dividing that space into two unequal portions. Sight was 15/XL. This case I believe to be quite unique in that it is one of spontaneous expulsion from the anterior chamber of the eye of a foreign body which had passed entirely through the cornea and was freely movable within the anterior chamber, and also unique in its expulsion without ulceration or other destructive change. That it must have passed entirely through the cornea and become freed from that tissue is evident by a comparison of the minute size of the offending body and the distance from the point of entrance to the point of injury in the iris, this being in a vertical direction at least 5 mm. Assuming, as was probably the case, that the aqueous humor had not been lost, the distance between the point of entrance and the point of injury to the capsule must have been considerably increased. It is probable, therefore, that the foreign body was driven entirely through the cornea, traversed the anterior chamber, cut the sphincter of the iris, lacerated the anterior capsule, after which it had fallen into the anterior chamber, where it had become surrounded by a mass of lymph; that the lymph had been ultimately absorbed and that the foreign body had made its way - whether at the exact point of entrance or not it is impossible to say -by absorption of the tissue in front of it, through the cornea - finally escaping unassisted from the eye. From the limited opportunities which I have had of consulting our literature, I have been unable to find any report of a similar case. Norris and Oliver mention that " very minute foreign bodies are sometimes spontaneously extruded from the eye," this taking place during attacks of inflammation when the minute body lacerates through its point of entrance. In most all of the cases referred to the inflammation was destructive and fatal to the eye. Since writing the above my attention has been called to a case of " spontaneous extrusion through the original point of entrance in the corneal membrane," in a report by Dr. Oliver, OPH.- IO
390
HARLAN: Delayed Union after Cataract Extraction.
published in the Annals of Ophthalmology for April, which presents more points of similarity to the case which I report than any other I have found. DISCUSSION.
DR. H. F. HANSELL. - About three years ago I reported a case similar in some respects to Dr. Worrell's, in which a piece of steel which had been in the an,terior chamber, according to the patient's story, for fifteen years, spontaneously extruded through the cornea. The wound of entrance was invisible. The steel gradually opened a way for itself through the cornea, and more than half of it was exposed when I saw it, so that I simply helped it out with a pair of forceps.
DELAYED UNION AFTER CATARACT EXTRACTION. BY GEO. C. HARLAN, M.D., PHILADELPHIA, PENN.
So far as I have been able to learn, there are no statistics to indicate how long the wound may remain open after extraction without necessitating a grave or hopeless prognosis of the final result. The text-books generally do not refer to the subject, and tabular reports of operations give no definite data. As some of my friends, as well as myself, have looked in vain for comfort when the anterior chamber has remained empty after the first few days, I have thought it might be worth while to bring the subject before the society. A few months ago I operated on a lady eighty-three years of age. She was in fair health, neither diabetic nor albuminuric, but too feeble to take a journey, and the operation was performed at her distant home, but she was left in charge of a good general surgeon and an experienced trained nurse. The operation was entirely smooth, there was no prolapse of the iris, and the pupil remained round and central. The usual compress and bandage were used, and after the second day the eye was carefully douched
