332

I3ULLER: A Poreign Body in the Retina. A FOREIGN BODY IN THE RETINA. BY DR. BULLER, MONTREAL, CANADA.

On the igth of January, I891, A. M., a healthy young man, granite worker, came on account of an injury to the left eye received six days previously. The account he gave of the injury was that while at his usual work he felt something strike the eye; and for half an hour afterwards there seemed to be a scum over the eye; this cleared off, all except a black spot seen constantly in front of the eye since the accident. On the fifth day after the injury, on getting up in the morning, he noticed for the first time a very considerable impairment of vision. Examination showed Rf=E V=6/12. The eye is painless, and presents a normal appearance, except that by focal illumination a minute scar is seen near lower corneal margin, and a corresponding minute aperture in the iris, at its lower periphery. This little opening is nearly circular, and not more than i mm. in diameter. There is no opacity in the lens, but some dark flocculi in the anterior part of the vitreous. The optic nerve has a blurred appearance, and the surrounding retina is decidedly cloudy, its veins dark and tortuous.- At a point about three discs below the papilla, and nearly on a line with its temporal border, there is a piece of metal lodged in the retina. It is of the sbape and relative size shown in the accompanying sketch which was kindly made for me by Dr. J. S. Booth, four days after T first saw the injured eye,- that is about ten days after the injury. The bright crystalline surface of the metal fragment is beautifully distinct, and only a little obscured near its upper end by a thin film of blood; a considerable quantity of blood could also be traced forward through the vitreous, and was most abundant anteriorly; evidently, the apices of one or more ciliary processes had been injured. Around the piece of metal is a narrow, sharply defined, densely white zone. There are no

13ULL1ER: A Poreign Body in the Retina.

333

haemorrhages or opacities in the retina elsewhere. Ordered rest of the eyes, protection from strong light, and a two-grain solition of atropia to be instilled twice daily. January 20th. The zone of opacity around the foreign body has distinctly increased since yesterday, and some similar opacity has formed in the retina a short distance from the metal, just at the end of a small blood clot in the vitreous. On the i8th of February, or twenty-six days after the injury reports that the eye feels quite well, but patient says it is a little dim. V.=6/12, or the same as at first visit. The optic nerve presents the appearance of a pronounced neuro-retinitis. There are several haemorrhages and some white spots in the retina between the foreign body and the macula lutea. The retina is cloudy all around the nerve and niacula, but especially so near the haemorrhagic spots mentioned. There is, in fact, a pretty extensive retinitis which, however, only reaches a short distance peripherally, and is most intense in the area including the foreign body, optic nerve, and macula. The. zone of opacity immediately around the metal fragment has almost disappeared, and there is now no blood ip the vitreous in its vicinity, but several dark clouds are still visible anteriorly. The fragment of metal is less glistening than formerly, though still fairly bright. The most remarkable change is in the choroid. For a considerable distance all around the foreign body there is an atrophy of the choroidal pigment, so that the choroidal vessels are clearly mapped out, while in the remainder of fundus they are barely distinguishable. April I2th. V. -6/9. The eye does not give him the least trouble or annoyance. The retinitis has mostly cleared up, though there is still some cloudiness in the area most affected, and the retinal vessels are larger and more tortuous than in the other eye. For a long distance around the macula the retina has a markedly "shot-silk" appearance. The piece of steel is still bright, and glistening in parts; the effusion in the retina has dispeared except a trace to the temporal side of the foreign body. Vitreous nearly free of blood.

334

3ULLER: A Foreign Body in the Retina.

--i

May ioth. V. -6/7.5 with each eye. r May 17th. V. -6/7.5 each. The injured eye, he says, is perfectly well. All the blood in vitreous, near foreign body, has cleared away, leaving only a little dotted opacity, best seen with +3d., above and external to the piece of metal. Anteriorly, the vitreous shows some stringy opacity. The retinal haemorrhages and cloudiness have gone, and its vessels are more normal in appearance. Only the papilla is -redder than usual, and its lower and outer margins are indistinct. The lower vessels, near the disc, have white borders for some little distance, and there is no further change in the appearance of the foreign body. From this date, I lost sight of the case, but after a good deal of searching managed to find him again on the I7th of this month. The eye, during the interval of fourteen months, has given him no trouble, and he imagines he can see as well as ever with it. This illusion was quickly dispelled since the usual test of vision only gives V. =6/27; and I find with the opthalmoscope a diffuse hyalitis with much fine opacity in the vitreous. Some of the longer opacities are grey and glistening, but most of them fine shreds and dots of a dark color. The optic nerve is red and swollen, its outlines quite obliterated; at the macula a shot-silk retina is dimly seen, but the foreign body has utterly disappeared from view, its former seat is marked by a small irregular patch of pigment like the remains of a blood stain. The vitreous humor is evidently abnormally fluid. These changes seems to foreshadow the usual disastrous result of foreign bodies remaining in the eye. It might, perhaps, have been better to have used a magnet and removed that piece of steel when we first saw it, but the total absence of urgent indications, the excellent vision during the first few weeks of observation, and the ultimate quiescent condition of the eye gave ample ground to hope we had to deal with a corpus alienum of benign tendency, one that had done its worst and would for the future be content to rest in peace. It is still something of a mystery why a clean foreign body should remain so long comparatively inert and then re-kindle

BULL: Case of Traumatic Irido-Choroiditis.

335

destructive changes. The initial retinitis, which it must be admitted was greater than there seemed to be reason for, had at one time entirely, or almost entirely, subsided; for months the piece of metal showed no signs of altering its position. It can hardly have been absorbed; if not, it has traveled a long distance from its original position. How this has been accomplished we can only conjecture. No doubt it was lightly imbedded in the retina, and the retaining lymph was gradually absorbed. Doubtless, too, the adjacent inflammatory process involved the vitreous at that part or perhaps throughout, rendering it more fluid, so that with the rotary movements of the eye the " wash " of the vitreous upon the projecting surface of the foreign body finally dislodged it from its position to roam at large within the eye, and hence the diffuse hyalitis, etc., now in progress. I hope to be able to report the outcome of this unusual case at some future meeting of this Society.

CASE OF TRAUMATIC IRIDO-CHOROIDITIS FROM CONTUSION OF THE EYEBALL, ENDING IN THE DEVELOPMENT OF INTRAOCULAR GLIOMA. IBY CHAS. STEDMAN BULL, M.D., NEW YORK CITY.

Maggie P., aged 3, was first seen on December 9, 189o, and the father gave the following history. On November 28th, while seated at the dinner table, the child was struck a severe blow on the left eye by a large tablespoon in the hands of an older child. The convexity of the bowl of the spoon struck the eye. The child immediately cried out and complained bitterly of the pain. The eye was bathed with cold water by the mother, and after a while the child stopped crying and complained that she could not see. The lids remained swollen for nearly a week, and there was some discharge of a muco-purulent character. On December gth, when I first saw the child, the swelling of the lids and the discharge had entirely ceased,

A Foreign Body in the Retina.

A Foreign Body in the Retina. - PDF Download Free
335KB Sizes 0 Downloads 10 Views