Part 34

_Encysted Tumours of the Eyelids._—These occur beneath the conjunctival lining of either the upper or under lid, but most frequently in the former. They form rapidly, but seldom attain any very considerable size; and may be found to contain, along with glairy fluid, a mixture of pus, or curdy matter. The contents, however, are generally glairy, rarely atheromatous. The cysts are very thin and adherent, and the tumour projects externally, forming a dusky red elevation of the integuments. They cause considerable deformity, watering of the eye, and stiffness and difficulty in moving the lids. On everting the eyelid, the contents of the tumour are seen shining through the distended conjunctiva, and present a bluish appearance. They are seldom single, and are not remediable but by operation. It is improper to attempt their extirpation from without, as there is a certainty of cutting completely through the eyelid, the inner covering of the cyst being merely attenuated conjunctiva. The lid is to be everted, and an incision made into the prominent and thin cyst with the point of a cataract knife; the contents can then be readily scooped out with the end of a probe. It is impossible to dissect out the tender cyst entire, and, when this is attempted, the cure can seldom be permanent. If, after incision and discharge of the contents, nothing farther is done, the disease will almost certainly return, in consequence of the remaining cyst reassuming a secreting action. The only effectual and radical cure is the application of a finely-pointed piece of caustic potass to the interior of the cyst, after discharge of the contents and cessation of bleeding. The cyst is thereby completely destroyed. A slip of soft lint, dipped in oil, is interposed betwixt the lid and eyeball, for an hour or two, in order to protect that delicate organ from the caustic. The wound suppurates and heals kindly, and no mark is visible, the incision having been made from within. I have had no instance of return of the disease since adopting this practice; and I have operated on many which had been previously treated by other and ineffectual means. The laceration of the cyst with a pointed probe is sometimes followed by a permanent cure, but it cannot be depended upon.

_Closure of the Eyelids_ may be either congenital, or a consequence of injuries, as burns of the parts. The closure may be complete or partial. In general it is partial, though perhaps extensive; and the adhesions can be readily separated by the point of a knife, or small probe having been previously introduced beneath; or a small and narrow probe-pointed bistoury may be conveniently used for the purpose. In the after-treatment means must, of course, be taken to prevent the lids from again adhering.

_Ectropion_, or eversion of the eyelids, may be produced, merely by swelling of the conjunctival lining protruding the lid: or the lid may be relaxed, and the conjunctiva may swell in consequence of repeated inflammation of the parts, caused by frequent and careless exposure; or the disease may be the result of contraction, by cicatrisation of the integuments of the face, as after burns, extensive superficial wounds in the neighbourhood of the eye, or the effect of periosteal disease of the orbit. The affection may exist to a greater or less degree, being in some instances scarcely visible, and not troublesome, whilst in others, the eyelashes lie on the upper part of the cheek, and the swollen granulated conjunctiva is exposed. The lower lid is generally the one which is affected. The disease may exist in both eyes, or only in one. In strumous habits both are frequently affected in a slight degree; and the upper lid, too, is sometimes turned a little outwards. When eversion is of long continuance, and complete or almost so, the conjunctival covering of the ball of the eye, and of the cornea, becomes dry and wrinkled; in short, the membrane completely changes its character, and becomes cuticular. In a lad who laboured eleven years under eversion of the upper and lower lids—arising from abscess and exfoliation of the external angular process of the os frontis, following a blow received when a boy—the conjunctiva was hard, wrinkled, scaly, and exactly similar to cuticle: this change of the membrane also extended over the whole cornea. The surface of the eye had lost its lustre, and vision was much impaired, the patient being able to distinguish only very bright objects. By such cases, continuity of the conjunctiva with the outer layer of the cornea is beautifully demonstrated.

Some of the most intractable of all cases of eversion are the result of burns. The constantly increasing contraction of the cicatrix draws either the upper or the lower lid far from its natural situation, and produces frightful deformity. The tarsal cartilages are greatly extended, and in any operation for the relief of the patient it is necessary to remove a portion before the lid can be properly adapted.

Great inconvenience is caused by the state of eversion: the surface of the eyeball is subject to inflammation, in consequence of being insufficiently protected; the change of its investing membrane is a serious evil; and in some cases the cornea becomes extensively ulcerated, unusually vascular, and opaque.

When the conjunctiva only is in fault, the deformity is slight, and the state of matters is readily ameliorated by excision of the relaxed portion. This is done by sharp curved scissors. As the wound gradually contracts, the eyelid is drawn inwards, and, on cicatrisation taking place, the parts have become restored to their healthy condition. Care, however, should be taken that too much of the swollen conjunctiva is not removed, otherwise the subsequent contraction may cause inversion of the lid. Combined with the above practice, relaxation of the lid itself will in many cases be remedied by removal of a portion of it in the form of the letter V, by means of a sharp-pointed bistoury: the edges of the incisions are afterwards put together by a point of interrupted suture. When eversion arises from a cicatrix of the integuments, the part in fault may be divided; but a temporary benefit only can be procured. For, during the healing of the wound, the parts again contract; and, though a portion of the conjunctiva is at the same time removed, the contraction internally will hardly counteract that which is going on externally. In order fully to obviate the evil of this contraction of the cicatrix in inveterate cases of ectropion, a form of plastic operation may be successfully resorted to. The cicatrix being dissected out, and the tarsal cartilage brought neatly into position, a piece of integument from the temple or cheek may be adapted, and a portion of a new eyelid formed. The parts may sometimes be brought into a good position without the necessity of borrowing any portion of integument. A V-shaped incision can be made, the apex pointing downwards, so as to loosen the under lid; and after it has been drawn upwards and put straight, the edges of the lower part of the exposed space are united by suture.

_Entropion_, or inversion, consists in the turning in of the tarsal margins of the lids, and generally takes place during inflammation and swelling of the conjunctival lining of the lid. During violent inflammation of the lid the conjunctiva and integuments are much swollen, and bulge out externally; by the projection the margin is forced mechanically towards the ball, and entropion takes place. But in this state of matters, should the lid be by any chance everted, and not replaced, then the bulging is from the conjunctival surface, and prevents the margin from regaining its former site, and permanent eversion or ectropion occurs. In fact, inversion and eversion, like phymosis and paraphymosis, exist from the same parts being put in different relation to each other. More permanent entropion is caused by the contraction which follows removal of tumours from the under surface of the lids, or destruction of large portions of the conjunctiva. The disease is most frequently met with in the upper lid.

_Trichiasis_ consists in a vicious bend of the eyelashes, or in a supernumerary growth in the rows or numbers of individual cilia, whereby they are inverted, and sweep the surface of the conjunctiva covering the cornea; thus great distress is caused by the friction of the hairs and edge of the lid on the sensible surface of the eyeball, and inflammation is frequently kindled and kept up by the continued irritation; it is accompanied by its usual distressing symptoms when seated in that organ, and too often followed by a greater or less number of untoward consequences. Sometimes only one or two hairs are at fault; in other instances, the half of the eyelash grows inwards; and sometimes there is a double row of cilia; one set being in the usual position, while the other projects against the eyeball. If proper means are not taken to remedy the evil, and moderate the irritation which it produces, the cornea becomes thickened and changed in structure; and vision, at first impaired and indistinct, may be entirely lost.

The symptoms may be for a time palliated by plucking out the faulty hairs, abstracting blood from the loaded vessels, and subsequently using ointments or collyria,—the best of which, perhaps, is the solution of nitrate of silver. In some cases it may be necessary to employ counter-irritation, as blistering the nape of the neck; and in all the general health must be strictly attended to. Other means may be required, and will be mentioned when treating of chronic ophthalmia.

The permanent cure of the disease is effected either by removal or by destruction of the roots of the cilia. The whole edge of the eyelid, or the offending part of it, is removed with a sharp narrow bistoury, the operator steadying the parts by laying hold of the cilia with the fingers of his left hand. It is necessary to remove the mere edge only, the cilia and their roots, and not the whole of the tarsal cartilage, as has been proposed.

Inversion of the lid, from contraction of a cicatrix in the conjunctiva, may be counteracted, by destroying with caustic, or removing with cutting instruments, a portion of the outer integuments, corresponding to the internal cicatrix. Forceps with broad points are used for taking up a fold of the skin, and an oval portion is then excised with a knife or scissors, cutting instruments being less painful and more precise than caustics. Of the latter, the sulphuric acid has been particularly recommended for this purpose. The contraction of the wound releases the cilia from the power of the internal cicatrix, and the parts are restored to their healthy state.

The term _Pterygium_ is employed to denote a thickened and vascular state of part of the conjunctiva. The diseased portion is generally of a triangular form, commencing at the inner corner of the eye, extending towards the cornea, gradually diminishing in breadth, and terminating in a sharp apex, either at the margin of the cornea, or somewhere between its margin and centre. The thickening is seldom great, but the vessels which traverse the thickened part are numerous, enlarged, and tortuous—are, in fact, varicose. The base of the pterygium is always on the circumference of the eye, generally at the inner corner, and its apex is seldom, if ever, situated beyond the centre of the cornea: frequently the sclerotic conjunctiva alone is affected. The motions of the eye are little disturbed by the disease, but vision is materially impaired when a considerable part of the cornea is covered. Pterygium is in general single, but sometimes, though very rarely, there are two or more pterygia in one eye; and, in such cases, the patient’s vision is seriously affected, in consequence of the apices of the different pterygia uniting and coalescing on the cornea, and investing the greater part of that organ with a thick and dark shade. When several occur, they sometimes unite throughout their whole extent, and cover the half or more of the eye. This disease is very common amongst negroes and persons residing in equatorial climates.

When the pterygium is of considerable size, extending over the cornea, the only remedy is excision. The apex of the web is laid hold of and pulled outwards by forceps or a hook, and the whole diseased part is then carefully dissected off with scissors, the incisions commencing at the apex, and being carried on to the base. The wound gradually contracts; and though an opaque cicatrix must form on the corneal surface, the speck is of much less dimensions than the space formerly occupied by the pterygium. If the web be thin and not exceedingly vascular, it may be sufficient to make a semicircular section of it transversely, by means of a hook and scissors, between its base and the margin of the cornea; its growth is thereby arrested, and there is a probable chance of its beginning to diminish, and ultimately disappearing. When it is small, and so situated as to cause no impairment of vision, it is prudent and good practice not to interfere with it at all.

DISEASES OF THE EYEBALL are numerous, and various in their nature. Some are acute, others chronic; and their attack is either sudden, or slow and insidious. Most of them are attended with pain and other annoying symptoms, and some cause loss of vision. Some are cured by internal means; others require surgical operations; and the cure is either complete and permanent, or palliative and temporary. Some destroy the organ, and others, still more malignant, cause extinction of life. All require much attention and care.

_Of Ophthalmia, or Inflammation of the Eye._—The symptoms and appearances of ophthalmia vary much according to the particular texture or textures affected. They require to be minutely attended to, that the treatment may be varied in such a way as to obviate any bad consequences which may be threatened. The great importance of the organ, and the danger to its structure and functions which is likely to occur from any other termination of the affection than resolution, must never be lost sight of.

We shall first treat of inflammation of the more external parts of the ball, an affection generally less dangerous than inflammation of the interior, but at the same time of more frequent occurrence, and produced by slighter causes.

Inflammation of the conjunctiva occurs in many individuals during very warm and sunny weather. At such a period, the eye is often excited by reflection of intense light from the surface of the earth; and is irritated by sudden exposure to a degree of light to which it has not been previously accustomed. Different directions of the sun’s rays, and different kinds of light, seem to exert different influences on the organ. The rays are most hurtful when they do not fall in a perpendicular direction on the eye, but slopingly or horizontally. Strong light from the moon, and light reflected from scarlet, are also particularly injurious. Undue exertion of the eye weakens it, and renders it prone to become inflamed. The eyes of infants are often violently inflamed, in consequence of imprudent exposure to light before they have been gradually accustomed to its stimulus. Again, inflammation is caused by imprudent exposure of the eye directly to cold, or by exposure of other parts causing suppression of their discharges, whether natural or not. Inflammation of the conjunctiva often follows suppression, however occasioned, of the menstrual or hemorrhoidal discharges, as also suppression of discharges from the urethra, from the Schneiderian membrane, or from behind the ears. Irritations in the neighbouring parts, as in the mouth during dentition, may also excite the disease. Immediate irritations, however, are the most frequent cause, as the lodgement of extraneous bodies on the surface of the organ—particles of sand, dust, snuff, pepper, or gunpowder, minute insects, loose or inverted eyelashes. By the presence of such substances, the eye is often kept in a very irritated state for a long period. The most violent conjunctival inflammation is sometimes produced by contact of gonorrhœal matter through carelessness. Occasionally metastasis of inflammation takes place from one eye to another; so that a person may be seen one day with severe inflammation of the right, and on the following day with a similar affection of the left, and the right entirely free from disease. Another cause, sometimes met with, of inflammatory action in the conjunctiva, is the lodgement of large foreign bodies in the orbit, with or without destruction of the eye; as splinters of wood, straws, rusty iron nails, sharp portions of stone, &c., penetrating the globe of the eye, or parts in the immediate neighbourhood. Upon removal of the cause, the redness, discharge of tears, pain, &c., sometimes subside without inflammation having been established, the vessels of the part regaining their contractility; but if the cause is continued for any considerable time the effects do not rapidly abate. Wounds and other injuries of the organ are generally followed by inflammation. But a simple clean wound or puncture made with a fine instrument, as in many operations, and in a favourable constitution, frequently produces little or no excitement of the part. The degree of excitement must of course depend upon the nature of the wound, the structure of the parts involved, the lodgement or not of the body by which the wound is inflicted, and many accidental circumstances. The eye may be injured by acids or by lime, and the textures acted upon chemically; again, the membrane may be wounded by pieces of hot metal, and then the destructive action is both chemical and mechanical: in both cases active inflammation of the injured conjunctiva is kindled. The state of the patient’s constitution modifies very much inflammatory action of the eye, however induced; and it has been observed, that dark eyes bear injury or incited action better than those of a light hue. Not unfrequently conjunctivitis is a secondary affection, accompanying eruptile diseases, as measles or small-pox.

In considering the disease, it is necessary to keep in mind the loose connection of the membrane with the subjacent parts, as well as its own texture and functions.

In conjunctival inflammation, the patient first feels a degree of pain and stiffness in moving the organ; and has always a feeling as if a foreign body were present, whether such is the case or not. There is also a degree of itching with a sensation of fulness in the part, and this is followed by redness of the membrane, becoming more and more intense. If the disease gain ground, the colour changes to a darkish red or purple hue. To the redness succeeds heat, with profuse and hot lachrymation. Then swelling supervenes, often to a great extent: the vessels, both veins and arteries, are much gorged, and effusion of serum or blood takes place into the loose cellular tissue which connects the conjunctiva to the sclerotic.

In some cases, the effusion in this situation is very considerable; lymph as well as blood is deposited, and a bulging forwards of the conjunctiva is produced; the stretched membrane becomes thickened, of a raw granulated appearance, and a bright scarlet hue, and the cornea appears sunk in the midst of the swelling, and almost hid by it: this state of matters is termed _Inflammatory Chemosis_, and only occurs when the excitement is very intense.

Blood is frequently effused beneath the conjunctiva in small quantity, in consequence of a bruise or other injury of the eye,—from violent exertion, as during coughing,—or from a less degree of inflammatory action than in the preceding case; but the swelling thereby occasioned is comparatively trifling, and the effusion is, in general, speedily absorbed. To this affection the term _Ecchymosis_ is attached.

In inflammation of the external parts of the eye, the redness begins from the margins of the organ, and gradually diffuses itself towards the cornea. Such is not the case in inflammation more deeply seated. There is intolerance of light in a slight degree, and the patient is inclined to keep the eyelids shut. At first the discharge from the conjunctiva and meibomian glands is increased and changed, and flows occasionally over the cheek, producing a scalding sensation. When the eyelids are at rest, as during the night, they become glued together by the viscid fluid from the meibomian follicles; but, if the inflammation increases in intensity, the discharge is arrested.

In external inflammation there is more or less constitutional disturbance, proportioned to the violence of the action and the irritability of the system. In most instances the patient complains of headache.

The above symptoms subside along with the inflammation; but, if this has been at all severe or protracted, distension of the vessels to a considerable degree continues, and the ophthalmia becomes chronic. This change from acute to chronic takes place at various periods of the affection, according to the intensity of the action, the nature of the cause, and the irritability of the constitution. And again, the second stage of ophthalmia may revert to the first, acute inflammation being rekindled by fresh irritation of the organ.