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1858.] 


Ophthalmology. 


279 


OPHTHALMOLOGY. 

43. Fpasms of the Eye after Extraction of Cataract. —Mr. White Cooper, in a 
clinical lecture ( Lancet , June 6, 1857), makes some interesting observations on 
this obstacle to success after extraction of cataract—an accident not sufficiently 
dwelt on in the books, and one which is not of uncommon occurrence. 

From the mode in which the muscles of the eye are arranged, any sudden 
and strong contraction of them must compress the eye, and may force the iris 
between the edges of the corneal section and interfere with the success of the 
operation. 

The symptoms of spasms of the muscles of the eye “ are sudden, acute, grasp¬ 
ing pain, with a sensation as if the eye were drawn back in the socket, generally 
attended with coruscations of light and colours, the result of compression of 
the retina. In the majority of cases it comes on within the first thirty-six hours 
after operation, generally during the brief interval between sleeping and waking, 
or just when the patient is dropping off to sleep, and is most marked in persons 
who have suffered from disturbance of the nervous system, as indicated by 
neuralgia, spasms, and cramps. 

The immediate indication is to tranquillize the nervous Bystem, and this 
object is best attained by a soothing cordial draught, composed of thirty drops 
of Hoffmann’s anodyne, twenty drops of Squire’s solution of bimeconate of 
morphia, and a drachm of the compound tincture of lavender, in an ounce of 
water. In some oases I have given six or eight drops of the tincture of Can¬ 
nabis Indica on a lump of sugar with excellent effect. The most grateful 
application to the eye itself is a fomentation of hot water, but in using this the 
utmost gentleness is necessary, the irritability of the eye being so great that a 
very slight touch will often bring on a return of the spasm. For the same 
reason, it is preferable to darken the room, thoroughly excluding the light from 
the patient, rather than to irritate the eye by compressing it with bandages. 
And here let me give you a hint; never allow a looking-glass to remain in the 
patient’s room. I have several times known much annoyance caused by a 
gleam of light falling on a mirror, and reflected to the patient’s face ; for the 
same reason have any chinks in the shutters stopped up; more mischief may 
be done by a bright ray of light streaming through a crevice, than by a con¬ 
siderable amount of general light, gradually admitted. 

It must be borne in mind that, for the better illustration of my subject, I 
have selected the most marked cases in my note-book. It by no means neces¬ 
sarily follows that destruction of the eye should follow spasm of the muscles; 
the immediate effect will almost certainly be disturbance of the section, and 
prolapse of the iris. The prolapse may, however, subside, or not be sufficiently 
great to interfere materially with the success of the operation ; or again, if the 
prolapse be so considerable as to cause obliteration of the pupil, vision may 
still be restored by an artificial pupil. 

Prolapse of the iris will be indicated by a slight oedematous swelling, com¬ 
mencing at the inner canthus, and stealing along the margin of the upper lid; 
the lid becomes exquisitely tender, so that the patient shrinks from the slightest 
touch, and there is generally the sensation of a foreign body under it. There 
is a copious discharge of scalding tears, the patient avoids light and the slightest 
movement of the lid. If you do manage to raise the lid, you will find the cornea 
thrown upwards, and there will he more or less redness of the conjunctiva and 
sclerotic ; simultaneously with these local indications the patient will complain 
of aching over the brow, extending down the side of the nose and cheek-bone, 
which is tender to the touch; the pain is aggravated at night. 

The treatment which I believe to be best for prolapse of the iris is, first and 
above all, absolute quiet of the eye ; the least handling or attempt to open the 
lids almost certainly brings on a return of the spasm, and of course keeps up 
the mischief. The object we should steadily keep in view is, to allow the iris 
to recover its position, and the section to become firm. The utter inability to 



280 Progress of the Medical Sciences. [Jan. 

raise the lid points out that Nature requires it to remain closed, in order that 
she may perform her work. 

It is generally recommended that the prolapse should be touched with nitrate 
of silver. In some cases I have seen this useful, in others hurtful; and on the 
whole, I am of opinion that time and quiet will attain the great object better 
and with less hazard than the use of the caustic. I remember a case in which 
I assisted the late Mr. Dalrymple. Three weeks after extraction the eye re¬ 
mained irritable, there being a small prolapse, but sight was returning favoura¬ 
bly. Wishing to hasten matters, Mr. Dalrymple touched the prolapse with 
caustic; violent pain came on, subacute inflammation followed, and the eye 
was lost. I believe that he used caustic no more in such cases. 

Time and quiet, then, are the main agents in the cure of prolapse of the iris ; 
whfen the cicatrix is forming, advantage may be derived from the use of bella¬ 
donna ; and if there be congestion, the application of a leech or two from time 
to time will be serviceable. There is one thing, however, which we are called 
upon to ameliorate, and that is the frontal neuralgia. An ointment, composed 
of one drachm of extract of opium to four drachms of strong mercurial oint¬ 
ment, well rubbed in at night, is often efficacious ; but I have found still greater 
relief afforded by painting the painful surface freely with a lotion composed of 
one grain of nitrate of silver dissolved in half an ounce of nitric ether. This 
sometimes acts like a charm in removing the pain. Another useful application 
is chloroform thus applied; a layer of cotton-wool is to be spread over the fore¬ 
head, then sprinkled with chloroform, and covered with oiled silk. The vapour 
is thus confined without coming in contact with the skin. 

There is a point in the after-treatment of cataract cases to which I would 
draw your attention—namely, the importance of avoiding any sudden startling 
of the patient, especially from sleep; as I look back upon the cases in my prac¬ 
tice in which there has been prolapse of the iris, I may ascribe this mainly to 
two causes—the eye being struck, or the patient being startled. It is not 
necessary that there should be a real blow ; a mere touch will be sufficient to 
cause a sharp action of the muscles of the lids and of the eye, and so the flap 
may be displaced. When, therefore, the eye is beiDg cleansed, the patient 
should always be warned when the sponge or rag is going to be applied ; for 
if not so prepared, a start will generally take place, and the eye may be struck. 

44. Diphtheritic Ophthalmia .—This is an affection almost unknown in France; 
nor is there any mention made of it, either in ancient or modem French trea¬ 
tises, on diseases of the eye. In Germany, however, much has been published 
regarding it; and, from the nature of its progress—from its severity, and its 
special characters, it is a malady deserving a place in our nosological tables. 
M. Gibert of Geneva, whose service as interne in the hospital of St. Eugenie 
afforded him an opportunity of observing the disease, gives a description of it, 
and from his remarks we subjoin the following particulars:— 

Diphtheritis of the mucous membrane of the eye is as general as that occur¬ 
ring in the larynx. In 1846 and 1847 M. Chassaignac described a purulent 
ophthalmia, which was accompanied by the formation of false membrane; this, 
however, is quite a different affection, bearing the same relation to the diph¬ 
theritis of the eye, which ulcero-membranous stomatitis does to true diphthe¬ 
ritic stomatitis. In ocular diphtheritis, the mucous membrane is dry, of a pale 
gray colour, and never during the whole period of the formation of false mem¬ 
branes, exhibits the granulations characteristic of purulent conjunctivitis. In 
the first case the circulation is almost completely interrupted, while in purulent 
ophthalmia the mucous membrane is highly vascular and the circulation active. 
According to Graefe, a characteristic sign of diphtheritis is, that on account of 
a more marked condition of stasis, the mucous membrane contains less blood 
serviceable for the purposes of circulation; moreover, in purulent ophthalmia, 
at first a lemon coloured secretion takes place, which quickly becomes turbid 
and purulent; in diphtheritis, there is at the first no secretion, the eye being 
completely dry; at a later period, a liquid of a dirty gray colour oozes away, 
composed, says Graefe, of tears, epithelial scales, and some colouring matter of 
the blood.