GUNSHOT
INJURIES
TO
THE
EYES.1
E. H. E. Stack, M.B., F.R.C.S., ; Specialist in Ophthalmology 2nd Southern General Hospital.
Capt., R.A.M.C.(T.F.)
EYE
INJURIES
AT THE 2ND SOUTHERN GENERAL
We have to deal at this cases a 1
hospital
with
to
the
HOSPITAL-
over one
hundred
month of trouble of some sort connected with the Read before the
Medico-Chirurgical Society,
December
15th.
eyes-
GUNSHOT INJURIES TO THE EYES.
About
one-third of these
are
due to
lrijury may affect the eye directly, cerebral trouble at a distance. We have seldom had
or
injury
or
I99 disease.
be the result of
An some
injuries to the inner table, because experience has shown the necessity of doing this operation as soon as possible after the injury has been received, and there are therefore great numbers done in France on the first possible opportunity. In cases of injury to the vault which have not been trephined, or in which, in spite of trephining, cerebral symptoms persist, then an oedema of the disc, which is very ?ften present, is a marked extra indication for exploring. to
trephine
for
^ in addition there is any contraction of the field of vision the indication is all the stronger, but when there is hernia Cerebri or other signs of local sepsis, then it is just as well not
to be in too A
great
a
hurry.
26 had a glancing wound of the right parietal bone suppuration and some necrosis of the outer table. weeks he was lethargic, slightly feverish, and had
man of
local 0r some
oedema of both discs.
On several occasions Colonel but I was loth to do this account of the local infection. When the piece of bone expiated he improved, and was soon able to get about, but he persisting tendency to slight giddiness. I don't know now hether I should have trephined or not.
Persistent 'hchell
Clarke
^
suggested exploration,
From a scientific point of view it is a great pity that our Patients have to be moved on so fast. The greater number them one only sees a few times, and then they go, to be
^eard
of
no
?Pportunity
of
more ;
getting
consequently an
I.
This Arisen in
is the most
"V
men
at first
but when
has
one
but
little
prognosis.
SHELL SHOCK.
interesting
the war, and the
Several
Edition,
idea of
problem
which has
is very difficult. seemed to be suffering from this
pathology
sight
they
eye
came
to be tested
they got
normal
200
MR.
nearly
or
astigmatism. first
possibly
time,
H.
normal vision with Some
I
E.
and
E.
STACK
glasses, usually hypermetropic
old blind eyes discovered for the
were
one or two were
able to prove this. Then again men who had lost the
malingerers, although
never was
sent to other
usually know, only
hospitals,
two cases of
sight
as we
of both eyes were had, as far as 1
have
blind in both eyes from any
men
cause. "
Many cases of blindness from shell shock rapidly. Putting all these facts together, it is wondered at that of
we
"
get well
not to he
have had but few to illustrate this
type
injury.
Private S. received no wound; a shell burst close in front and he fell down. He noticed that at first he saw very but soon recovered badly, sufficiently to see pretty well with the of
him,
left eye. On admission all details normal except some photophobia in a bright light, and a little lachrymation in both eyes, n? scotoma or Berlin dimness, the fundus being quite natural, and there was no error of refraction. The vision in the right eye a
week later in the
right
60
was
eye
and in the left ?. Vision 5 6 much better, I think about
was 7?
unfortunately I have omitted to note it. He showed n? signs of neurosis, and was quite sure that previously ^ vision in both eyes was good ; he had always used his right eye for shooting. Another case was complicated by having had epilepsy a rare intervals all his life. He was in a highly neurotic state, an1 when I first examined him he could only count fingers. However but
other
a
few minutes later he
was
persuaded
to read ?with each
two glasses in the frame, one being a + 1 and the 1, which of course exactly neutralised each other.
having a
??
I
am
ordinary
eye
perception of light only ; some vitreous hemorrhage witn 6 6 a red reflex ; vision later Fundus c. 2, spherical, and a cyl
-and
?
^
.seen a
little
foggy
and disc natural.
GUNSHOT INJURIES TO THE EYES.
Traumatic cataract.?There have been
5?f
these,
most of whom moved
?peration
arose, while the
on
a
before the
others, for
Were advised to
203
good many question of other,
some reason or
to
later date.
postpone operation point when a traumatic cataract should removed ; some advise early excision instead of needling, ^aiming less liability to irremovable bits of capsule, while ?n the other hand some lenses become fluid, and can be almost c?nipletely evacuated through a small incision. It is not
6.
settled
Vitreous
regards
better ?*
a
a
opacities.?The prognosis is much worse as vision, but occasionally there is a much
return of
result than
would
one
expect.
Sergeant G., aged 29, was struck in the right eye by a piece shrapnel. He did not notice anything for five weeks, and
^hen
muscas
vetinoscopy
On admission vision R.
appeared.
c.
5
+ .75
in each eye showed between 4 and 5 D. of
^etropia. Ophthalmoscopic
-?
5
hyper
examination revealed extensive fine without any change in the retina. So that he had perfect vision in spite of a blow which caused emorrhage into the vitreous. .
Vltreous opacities ,
Private G. had a rifle ma]ar bone. There was no red reflex
wound which fractured his
right
obtainable except an occasionallya black curtain ; with oblique could be seen moving behind lens, which had not been damaged. I rather suspect a PJcule of bone perforated the globe in this case, as the tension
small red spot like hole in .5jen urination dark masses of clot a
as
low.
7as
the
Changes
most vulnerable
Commotio Cases
at the macula.?Haab considers the macula
in which after
$?be there
^acula
point
retinae is a
of the fundus.
a term
which should be confined to
blow in the
is oedema of the retina
or at
neighbourhood
near
the
spot hit,
or on
the
or at
the
both.
This oedema
is said to be due to vascular
changes following
MR.
204 the anaemia caused how such
by
E.
E.
H.
STACK
the blow,
though
transient anaemia could
a
it is difficult to see"
this effect.
give
This oedema at the macula may pass off in four or fiv^ days. Collected cases show that permanent central defective vision results in about retinitis
Rarely in
some
a
third of the
cases.
proliferans follows, showing
there is retinal
I have had
least
that at
hemorrhage. cases showing this
macular oedemaonly The first I have already mentioned under the head of sub' conjunctival hemorrhage. In it there was a faint whitish haze round
passing
a
two
red macula and two
from this
improved
to
R., aged 25,
downwards,
I could find
no
2nd Grenadier
of his
but
or
even
three radial stn#
when his vision
evidence of
a
had
centralscotoma-
Guards, had been the crack shot
regiment, using his right eye. Ten days previous to admission a a flap of skin on the right eyebrow.
,
rifle bullet had turne He was not unconsciouS up at the time, and when I saw him his vision in the right eye ^vaS reduced to perception of light. The disc was very white, but th arteries were not small; there was well-marked faint whitis oedema round the macula. He was in for several weeks with011 showing any improvement in his vision. There have been
no
cases
showing
the so-called "hole &
the macula."
afl^ it had two peculiarities. The man said he had not been struck 8.
Ruptured
but that
a
choroid.?I have
seen
only
one
shell had burst close in front of him.
of these,
The
rup^ni?
had the
typical vertical crescentic appearance, but situated to the temporal side of the macula, which ^ normal, instead of the usual situation between it and disc.
His vision
was
p. 1.
e
only.
^ 9. Foreign bodies in the eye.?One situated in the lens infected on admission, and the eye had to be removed. Another
was
a
small
piece
of
shrapnel
buried very
dee?
GUNSHOT INJURIES TO THE EYES. 111
205
the cornea, where it had been for six weeks without
giving
^uch trouble, and scarcely interfering with vision. With Mr. Richardson Cross's kind assistance I removed it ^vith Haab's 10. a
giant magnet
Foreign
piece
ln the
at the
Eye Hospital.
bodies in the orbit.?In
one
of shell from the frontal sinus and left
sphenoidal
sinus.
He had
I removed
case
larger
a
bit
oedema of his disc,
some
He went out healed without any
very good vision.
symptoms. 11.
before 12.
Ruptured globes
had
almost
all been
enucleated
admission.
Papillcedma.?There have, of course, been numerous category, but I do not intend going through as they are better dealt with by the neurologist. One
Cases in this
^herri,
Point noticeable about them is that many have, in addition *? the swelling of the papilla, a ring of oedema in the retina
Grounding the disc, the swelling is not often more than arid I have 13-
seen
Certainly behind the
due to
There have been three
IV.
Most ??ps in
rupture
of the
optic
One nerve
of these our
cases of
quadrantic
scotoma
occipital region.
LACHRYMAL OBSTRUCTION. are
not due to
injury,
and occurred in
neighbourhood who had not seen active service, to emphasise the good and rapid results
should like
?btained by doing There ^0W who
Ca-ttie
damage
have been four of these. or
D.,
hemorrhages.
eye.
to wounds in the
t I
with retinal
Optic atrophy.?There was
14-
no case
2
is
West's intranasal
one man
operation
on
in the 2nd Southern General
the
sac.
Hospital
He under my care at Southmead last year. in with the first batch of wounded which we had. was
206
progress of the
A bullet had crossed his and he
rapidly,
He has had turbinated
blockage sac or a
bone
Home Service
adherent
operation,
to
because a
glass
man a
with
duty.
the
He will
septum, require an
a
and
complete
excision of the
if the nasal condition
Plastic surgery of the lids has been but claims no special mention. One
healed
necrosis of the ethmoid with the inferio1"
of the tear duct.
West's
The external wounds
nose.
was sent on some
medical sciences.
cut lower
permits. frequently performed,
lid seemed much
bullet had smashed his eye, which
amused
happened
to be
one.
The three to these eye
things
which have struck
me
most with
the number of
regard
firstly, injuries glancing the eyeball, which, while causing considerable damage to the eye, have left untouched the surrounding soft parts ; secondly, the frequency with which blows have of brought to light for the first time quite marked degrees hypermetropia; and, thirdly, the number of men who have acquired nystagmus as the result of head injuries. wounds of
have been,
INJURIES
TO
THE
EYES.1
E. H. E. Stack, M.B., F.R.C.S., ; Specialist in Ophthalmology 2nd Southern General Hospital.
Capt., R.A.M.C.(T.F.)
EYE
INJURIES
AT THE 2ND SOUTHERN GENERAL
We have to deal at this cases a 1
hospital
with
to
the
HOSPITAL-
over one
hundred
month of trouble of some sort connected with the Read before the
Medico-Chirurgical Society,
December
15th.
eyes-
GUNSHOT INJURIES TO THE EYES.
About
one-third of these
are
due to
lrijury may affect the eye directly, cerebral trouble at a distance. We have seldom had
or
injury
or
I99 disease.
be the result of
An some
injuries to the inner table, because experience has shown the necessity of doing this operation as soon as possible after the injury has been received, and there are therefore great numbers done in France on the first possible opportunity. In cases of injury to the vault which have not been trephined, or in which, in spite of trephining, cerebral symptoms persist, then an oedema of the disc, which is very ?ften present, is a marked extra indication for exploring. to
trephine
for
^ in addition there is any contraction of the field of vision the indication is all the stronger, but when there is hernia Cerebri or other signs of local sepsis, then it is just as well not
to be in too A
great
a
hurry.
26 had a glancing wound of the right parietal bone suppuration and some necrosis of the outer table. weeks he was lethargic, slightly feverish, and had
man of
local 0r some
oedema of both discs.
On several occasions Colonel but I was loth to do this account of the local infection. When the piece of bone expiated he improved, and was soon able to get about, but he persisting tendency to slight giddiness. I don't know now hether I should have trephined or not.
Persistent 'hchell
Clarke
^
suggested exploration,
From a scientific point of view it is a great pity that our Patients have to be moved on so fast. The greater number them one only sees a few times, and then they go, to be
^eard
of
no
?Pportunity
of
more ;
getting
consequently an
I.
This Arisen in
is the most
"V
men
at first
but when
has
one
but
little
prognosis.
SHELL SHOCK.
interesting
the war, and the
Several
Edition,
idea of
problem
which has
is very difficult. seemed to be suffering from this
pathology
sight
they
eye
came
to be tested
they got
normal
200
MR.
nearly
or
astigmatism. first
possibly
time,
H.
normal vision with Some
I
E.
and
E.
STACK
glasses, usually hypermetropic
old blind eyes discovered for the
were
one or two were
able to prove this. Then again men who had lost the
malingerers, although
never was
sent to other
usually know, only
hospitals,
two cases of
sight
as we
of both eyes were had, as far as 1
have
blind in both eyes from any
men
cause. "
Many cases of blindness from shell shock rapidly. Putting all these facts together, it is wondered at that of
we
"
get well
not to he
have had but few to illustrate this
type
injury.
Private S. received no wound; a shell burst close in front and he fell down. He noticed that at first he saw very but soon recovered badly, sufficiently to see pretty well with the of
him,
left eye. On admission all details normal except some photophobia in a bright light, and a little lachrymation in both eyes, n? scotoma or Berlin dimness, the fundus being quite natural, and there was no error of refraction. The vision in the right eye a
week later in the
right
60
was
eye
and in the left ?. Vision 5 6 much better, I think about
was 7?
unfortunately I have omitted to note it. He showed n? signs of neurosis, and was quite sure that previously ^ vision in both eyes was good ; he had always used his right eye for shooting. Another case was complicated by having had epilepsy a rare intervals all his life. He was in a highly neurotic state, an1 when I first examined him he could only count fingers. However but
other
a
few minutes later he
was
persuaded
to read ?with each
two glasses in the frame, one being a + 1 and the 1, which of course exactly neutralised each other.
having a
??
I
am
ordinary
eye
perception of light only ; some vitreous hemorrhage witn 6 6 a red reflex ; vision later Fundus c. 2, spherical, and a cyl
-and
?
^
.seen a
little
foggy
and disc natural.
GUNSHOT INJURIES TO THE EYES.
Traumatic cataract.?There have been
5?f
these,
most of whom moved
?peration
arose, while the
on
a
before the
others, for
Were advised to
203
good many question of other,
some reason or
to
later date.
postpone operation point when a traumatic cataract should removed ; some advise early excision instead of needling, ^aiming less liability to irremovable bits of capsule, while ?n the other hand some lenses become fluid, and can be almost c?nipletely evacuated through a small incision. It is not
6.
settled
Vitreous
regards
better ?*
a
a
opacities.?The prognosis is much worse as vision, but occasionally there is a much
return of
result than
would
one
expect.
Sergeant G., aged 29, was struck in the right eye by a piece shrapnel. He did not notice anything for five weeks, and
^hen
muscas
vetinoscopy
On admission vision R.
appeared.
c.
5
+ .75
in each eye showed between 4 and 5 D. of
^etropia. Ophthalmoscopic
-?
5
hyper
examination revealed extensive fine without any change in the retina. So that he had perfect vision in spite of a blow which caused emorrhage into the vitreous. .
Vltreous opacities ,
Private G. had a rifle ma]ar bone. There was no red reflex
wound which fractured his
right
obtainable except an occasionallya black curtain ; with oblique could be seen moving behind lens, which had not been damaged. I rather suspect a PJcule of bone perforated the globe in this case, as the tension
small red spot like hole in .5jen urination dark masses of clot a
as
low.
7as
the
Changes
most vulnerable
Commotio Cases
at the macula.?Haab considers the macula
in which after
$?be there
^acula
point
retinae is a
of the fundus.
a term
which should be confined to
blow in the
is oedema of the retina
or at
neighbourhood
near
the
spot hit,
or on
the
or at
the
both.
This oedema
is said to be due to vascular
changes following
MR.
204 the anaemia caused how such
by
E.
E.
H.
STACK
the blow,
though
transient anaemia could
a
it is difficult to see"
this effect.
give
This oedema at the macula may pass off in four or fiv^ days. Collected cases show that permanent central defective vision results in about retinitis
Rarely in
some
a
third of the
cases.
proliferans follows, showing
there is retinal
I have had
least
that at
hemorrhage. cases showing this
macular oedemaonly The first I have already mentioned under the head of sub' conjunctival hemorrhage. In it there was a faint whitish haze round
passing
a
two
red macula and two
from this
improved
to
R., aged 25,
downwards,
I could find
no
2nd Grenadier
of his
but
or
even
three radial stn#
when his vision
evidence of
a
had
centralscotoma-
Guards, had been the crack shot
regiment, using his right eye. Ten days previous to admission a a flap of skin on the right eyebrow.
,
rifle bullet had turne He was not unconsciouS up at the time, and when I saw him his vision in the right eye ^vaS reduced to perception of light. The disc was very white, but th arteries were not small; there was well-marked faint whitis oedema round the macula. He was in for several weeks with011 showing any improvement in his vision. There have been
no
cases
showing
the so-called "hole &
the macula."
afl^ it had two peculiarities. The man said he had not been struck 8.
Ruptured
but that
a
choroid.?I have
seen
only
one
shell had burst close in front of him.
of these,
The
rup^ni?
had the
typical vertical crescentic appearance, but situated to the temporal side of the macula, which ^ normal, instead of the usual situation between it and disc.
His vision
was
p. 1.
e
only.
^ 9. Foreign bodies in the eye.?One situated in the lens infected on admission, and the eye had to be removed. Another
was
a
small
piece
of
shrapnel
buried very
dee?
GUNSHOT INJURIES TO THE EYES. 111
205
the cornea, where it had been for six weeks without
giving
^uch trouble, and scarcely interfering with vision. With Mr. Richardson Cross's kind assistance I removed it ^vith Haab's 10. a
giant magnet
Foreign
piece
ln the
at the
Eye Hospital.
bodies in the orbit.?In
one
of shell from the frontal sinus and left
sphenoidal
sinus.
He had
I removed
case
larger
a
bit
oedema of his disc,
some
He went out healed without any
very good vision.
symptoms. 11.
before 12.
Ruptured globes
had
almost
all been
enucleated
admission.
Papillcedma.?There have, of course, been numerous category, but I do not intend going through as they are better dealt with by the neurologist. One
Cases in this
^herri,
Point noticeable about them is that many have, in addition *? the swelling of the papilla, a ring of oedema in the retina
Grounding the disc, the swelling is not often more than arid I have 13-
seen
Certainly behind the
due to
There have been three
IV.
Most ??ps in
rupture
of the
optic
One nerve
of these our
cases of
quadrantic
scotoma
occipital region.
LACHRYMAL OBSTRUCTION. are
not due to
injury,
and occurred in
neighbourhood who had not seen active service, to emphasise the good and rapid results
should like
?btained by doing There ^0W who
Ca-ttie
damage
have been four of these. or
D.,
hemorrhages.
eye.
to wounds in the
t I
with retinal
Optic atrophy.?There was
14-
no case
2
is
West's intranasal
one man
operation
on
in the 2nd Southern General
the
sac.
Hospital
He under my care at Southmead last year. in with the first batch of wounded which we had. was
206
progress of the
A bullet had crossed his and he
rapidly,
He has had turbinated
blockage sac or a
bone
Home Service
adherent
operation,
to
because a
glass
man a
with
duty.
the
He will
septum, require an
a
and
complete
excision of the
if the nasal condition
Plastic surgery of the lids has been but claims no special mention. One
healed
necrosis of the ethmoid with the inferio1"
of the tear duct.
West's
The external wounds
nose.
was sent on some
medical sciences.
cut lower
permits. frequently performed,
lid seemed much
bullet had smashed his eye, which
amused
happened
to be
one.
The three to these eye
things
which have struck
me
most with
the number of
regard
firstly, injuries glancing the eyeball, which, while causing considerable damage to the eye, have left untouched the surrounding soft parts ; secondly, the frequency with which blows have of brought to light for the first time quite marked degrees hypermetropia; and, thirdly, the number of men who have acquired nystagmus as the result of head injuries. wounds of
have been,
