PHOTOPSY FROM AN INJURED EYE, PERSISTING SIX MONTHS AFTER ENUCLEATION. By DR. J. J. B. VERMYNE, New Bedford, Mass. MR. F. TR., 53 years old, stonecutter, while engaged at his trade, received an injury of his left eye. This happened during the latter part of August, I876. He was aware of the entrance of a foreign body in the eye-whether a piece of iron or a piece of stone-by a sudden, dull pain and an appearance as a large red ball before the eye, which was soon found to be entirely blind. There was severe conjunctivitis of the builbtus dturing a few days, but this and the pain gradually subsided under continued application of cold water, while at the same timiie the vision seenmed to improve. This improvement, however, ceased very soon, and he found that the eye was growing blind, for which he camiie to consult me on September 26th, nearly one mionth after the injury. He is a strongly built man, has always been temperate in his habits, and with the exception of a slight rlleuniatic affection, has never had any sickness. He has received frequent injuries to the eyes fromii the presence of foreign bodies, but they could always be easily removed and never left any trace. There was no redness; the corniea showed a smiiall scar very near the miiargin on temporal side, otherwise clear. Iris same color as other eye; has a little below the horizontal nmeridian, and slightly inward and upward of the corneal opacity, a separation in its continuity in the form of a rent nearly one line in length, encroaching neither upon the pupillary or ciliary margin. Corresponding in direction with this rent is a posterior synechia of the iris. The lens is cataractous, more dense on the temporal side, in the immlediate neighborhood of the synechia, less in the centre, and but very slightly on the nasal side, where fingers are counted at about two feet distance. Examination with the ophthalmiioscope after instillation of atropia shows only the one synechia above nmentioned, light reflex from the fundus throuigh the rent in the iris-tissue, faint reflex from the fundus oculi through pupil, except at the nasal side; but even there no details of the findus could be seen. There is not the slightest pain, his only comiplaint being the loss of vision. With the almost indubitable presence of a foreign body within the eye, and the imipossibility of an
450 exact location, I advised enucleation of the injured eye, which was refused.. After explaining, however, the danger to the other eye from sympathetic ophthalmia, he promiised to submit to the operation as soon as his right eye shotuld indicate the slightest trouble, or when inflammatory symptomis shouild appear in the inijured eye. I thought of the possible chance that the foreign body, which, according to the directioni of the corneal and iris wouind, had penetrated in a slightly oblique direction, might be held in the lens, and of a removal of both by cataract operation, and therefore was perfectly willing to postpone enucleation. The lpatient went to work again, and had no trouble until the end of December, I876; the opacity of the lens was meanwhile increasing. At the tinme menitioned, being at work in the cemetery on a cold day laying curbstones, he was attacked bv rheumatic pains, which, after a couple of days, seemed to localize more in the head, especially in the supraorbital region, and were accormpanied with scintillations from the left eye, appearing in the form of a red smoke, as from a distant fire, as soon as he closed his eyes for sleep. The frequency and duration of these perceptions varied very much; usually, however, they were severe enough to rob him of any refreshing sleep. To the different means employed, hirudines at tempora, blisters, miorphine internally and hypodermically, bromide of potassiumll, iron and quinine, hydras choralis, etc., there was an occasional response with temporary relief, but sooIn they had to be given up, as not producing any lasting benefit. Both the pain and the photopsy gradually increased; the pain, extending first over the temporal region and then farther backward, until the whole head was affected, was almost continuous, with nightly exacerbations. The photopsy assumed the form of strong flashes of light darting out of the eye, to a length of from 5 to 6 inches, making their appearance every night when he tried to go to sleep, occasionally in day-time. When the photopsy was at its worst he often imagined hearing a hissing sound accompanying the flash. During all this time there was never any redness of the eye, nor sensitiveness on pressure in the ciliary region; and the uninjured eye, although repeatedly examnined functionally and ophthalmoscopically, never showed the slightest trouble, although at the worst stages of his suffering he thought that occasionally a flash of light would dart out of that eye, too. I was at a loss to explain these severe syDl)toMs. When they first made their appearance there was conisiderable swelling of the cataractous lens; but after some timiie not only the swelling subsided, but absorption of the cataract tool place, withotut any abatenment in the other symptoms. At last
451 there was only a very slight webby opacity left in the ptupil, a little more dense in its lower part. With the ophthalnmoscope light reflex was not only obtained froml the fundus, buit here and there some of the details becanme visible in some detached parts of the retinal bloodvessels. A clear view of the fundus could niever be obtained on account of a large numiiber of thick floating opacities in the vitreous. Vision began to show again to the amouint of -s6o Sometimes I suspected that I could see the foreign body, but I never felt sure enough to locate it. Again I supposed that the foreign body might not be imiibedded, but free in the posterior chamber, and that with the watery condition of the vitreous, evident from the rapid and multiple movements of the opacities in that body, the foreign body might change its place, and impinge directly upon the optic disk when he tried to lie down for sleep. I therefore advised sleep in a more or less sitting position, but of no avail. The trouble appeared just the same then as before. Finially, fearing that death fromii exhaustion, or insanity would follow as a result of this continued suffering, but with great nisgivings that the trouble might no longer be local, but central, at the patient's earnest request I enucleated the left, inijured eye on January 26th of this year, nearly I 7 months after the injury. Fully i inch of the trunk of the optic nerve was removed with the eyeball. The section of the nerve appeared normiial. On opening the eye the vitreous was found very fluid, and in the retina, about one optic disk distance toward the nasal side, was found a piece of iron, about one line in length and half a line broad and thick, witlh one edge a little sharper than the other, however, so loos'tly irnbedded in the tissues, that it falls out of itself, showing a slight unevenness in the place where it had lodged. The result of the operation showed that my misgivings were not without cause. For although the pain and photopsy have somewhat diminiished, at this momnent, six mlonths after enucleation, they still persist. The same remedies as before enucleation were also resorted to after this operation, in addition to Fowler's solution, ergot, and iodide of potassiulm, but without any more effect than before. A careful regulation of his diet, and iron and quinine persistently exhibited for quite a long time, have imiiproved his physical appearance, and this, with the fact that I tried to reassure him that the photopsy would slowly disappear when his general health should improve, has probably contributed greatly to the decrease of the nervous excitenment he was laboring under before the operation. But there is still pain in the region of the ophthalmiiic branch of the trigeminus, and in that of the auricularis and occipitalis, with occa-
452
sional rheumatic pains in the limbs, increasing with the slightest cold or exposure. The photopsy is also present, though the flashes are not quite so severe; they are not so extensive or so bright, do nlot last so long as before, so that since a couiple of months he can obtain sleep without any artificial nmeans. The flashes are now always unilateral on the side of the enucleated eye. The vision of the right eye is perfectly normal. The conjunctival sac of the enucleated eye has a perfectly healthy appearance, and pressure with a probe-point on different parts of this membrane does not produce any pain or photopsy. The neuralgic pains still continue to show their nightly exacerbations. I have been unable to account with certainty for the relations between the probable occasioning cause of the trouble, the foreign body within the eye, and the subsequent nervous symptoms. Although the foreign body itself could not be seen, yet its retention within the eyeball could be suspected by tracing its path through cornea, iris, and lens. For this reason I was afraid of the danger of sympathetic ophthalmia, and of this I gave due warning. But I was not prepared for the symptoms as appearing in our case, especially with such severity, and yet without any comiplaint of pain in the eyeball, nor the slightest redness or other visible symiiptomiis of inflamml)ation of the eye; neither was I able to obtain nmuch informiiation in the works on ophthalmic and nervous diseases at my conimand. The only notices on photopsy bearing to some extent upon the subject were in Wharton Jones, 3d American edition, page 300: " Analogous appearances of fiery scintillations, flashes of light, and colored coruscations, occuring spontaneously, are symptomiis of irritation or excitemiient of the optic nervous apparatus-cerebral or ocular-from inflamm'atory congestion of the choroid, as above nmentioned, rather than from inflammlilatory congestion of the retina. As such inflamiimatory congestion may end in amaurosis, so the luminotus and colored spectra are symptonms of incipient amaurosis. They may continue to appear, however, after all visual sensibility is lost." Leber, in Graefe-Saemisch Handbuch der gesammten Augenheilkunde, Vol. V., p. 1046, says that " photopsy can be caused by increased filling of the blood-vessels, inflammation or unknown disturbances of the nervous systemii, as internal cause of irritation, or by much coarser, mechanical influences, dragging or compression by shrinking masses of connective tissuie, calcification, etc. ;" and a little farther: " also by comiipression of the optic nerve from masses of connective tissue in the process of shrinking after injury or after contusion of the stump in enucleation. In
453 some cases this photopsy can becom.e so intense as to produce hallucinations, so that, it may cause anxiety for the mind or life. As a rule, they are entirely remiioved by enucleation of the bulbus or resection of the optic nerve stunmp." Stellwag v. Carion, page 850, mentions the fact of plhotopsy continuing after complete amiiaurosis has set in, and in speaking of causes says, that optic hyperaesthesia appears as a symptom of congestive or inflammatory brain disease, delirium potatorumii, narcotic poisoning, neuralgia of the trigetlminus (Alexandler), etc. These few points, applied to the case reported, would allow of an explanation of the persistency of photopsy in two ways: the first cause was either intraocular, the foreign body witlhin the eye, or the symptom depended upon an affection of the trigenminus, and might have been favored by the presence of that foreign body. In regard to the first explanation, it could be presumiied that the pressure of the foreign body upon the choroid, as stated by Wharton Jones, was the first cause of the photopsy. Although at no timiie while the patient was under my observation, a period of sixteen imonths before enucleation, could any symptoimls of active inflammation be observed, yet some disease of the choroid miiight be suspected from the watery condition of the vitreous humilor and the numerous large opacities within that body. The persistency of the symptomi after enucleation might depend uiponi the same intrinsic action of the brain, by which strong and lasting visual imiipressions are so forcibly implanted in the apparatus of vision, that their afterimages are either continuially present in the field of vision, or at least make their appearance as soon as the patient begins to think of themii. 'This latter condition nmight be highly increased by the great excitability of the centrlal nerve systemii, fromii pain, sleeplessness, and especially from the anxiety cauised by being conscious of the presence of some foreign bo:dy and the possible dangers it miight bring. That such an excitable condition existed in reality is proved by the existence of aural illusion, in the form of the hissing sound accompanying the flashes of light, when they were the worst. In favor of this explanation are the facts that there never was any trouble before the eye was injured, that the impressions were at first entirely, later chiefly unilateral, and that, although by no means removed by the removal of the foreign body, they are decidedly less severe than before. The second opinion would rest especially on the fact of this appearance aftei exposure, simultaneously, or almost so, with pains in
454 the region of the ramus ophthalmicus of the trigeminus, and of their persistency with the pains after enucleation, while it might be strengthened by the negative evidence of absence of visible irritation in the eye. In connection with the trigeminus affection there could be some local hyperaeiimia of the meninges at the base of the cranium, and therefrom pressure on some part of the trunk of the n. opticus. rhe excitability of the cerebral system would work here the saime as with the other explanation. That the persistency of optic hyperaesthesia in this case should depenid upon pressure or dragging from shrinking masses of connective tissue I cannot believe, since the section of the nerve, which as a matter of precaution was removed for quite an extent, appeared healthy. In this respect I believe that my patient would readily submit to resection of the stuimip as advised by Leber, if I could give him the certain promise of relief, which of course I would not dare to do.
450 exact location, I advised enucleation of the injured eye, which was refused.. After explaining, however, the danger to the other eye from sympathetic ophthalmia, he promiised to submit to the operation as soon as his right eye shotuld indicate the slightest trouble, or when inflammatory symptomis shouild appear in the inijured eye. I thought of the possible chance that the foreign body, which, according to the directioni of the corneal and iris wouind, had penetrated in a slightly oblique direction, might be held in the lens, and of a removal of both by cataract operation, and therefore was perfectly willing to postpone enucleation. The lpatient went to work again, and had no trouble until the end of December, I876; the opacity of the lens was meanwhile increasing. At the tinme menitioned, being at work in the cemetery on a cold day laying curbstones, he was attacked bv rheumatic pains, which, after a couple of days, seemed to localize more in the head, especially in the supraorbital region, and were accormpanied with scintillations from the left eye, appearing in the form of a red smoke, as from a distant fire, as soon as he closed his eyes for sleep. The frequency and duration of these perceptions varied very much; usually, however, they were severe enough to rob him of any refreshing sleep. To the different means employed, hirudines at tempora, blisters, miorphine internally and hypodermically, bromide of potassiumll, iron and quinine, hydras choralis, etc., there was an occasional response with temporary relief, but sooIn they had to be given up, as not producing any lasting benefit. Both the pain and the photopsy gradually increased; the pain, extending first over the temporal region and then farther backward, until the whole head was affected, was almost continuous, with nightly exacerbations. The photopsy assumed the form of strong flashes of light darting out of the eye, to a length of from 5 to 6 inches, making their appearance every night when he tried to go to sleep, occasionally in day-time. When the photopsy was at its worst he often imagined hearing a hissing sound accompanying the flash. During all this time there was never any redness of the eye, nor sensitiveness on pressure in the ciliary region; and the uninjured eye, although repeatedly examnined functionally and ophthalmoscopically, never showed the slightest trouble, although at the worst stages of his suffering he thought that occasionally a flash of light would dart out of that eye, too. I was at a loss to explain these severe syDl)toMs. When they first made their appearance there was conisiderable swelling of the cataractous lens; but after some timiie not only the swelling subsided, but absorption of the cataract tool place, withotut any abatenment in the other symptoms. At last
451 there was only a very slight webby opacity left in the ptupil, a little more dense in its lower part. With the ophthalnmoscope light reflex was not only obtained froml the fundus, buit here and there some of the details becanme visible in some detached parts of the retinal bloodvessels. A clear view of the fundus could niever be obtained on account of a large numiiber of thick floating opacities in the vitreous. Vision began to show again to the amouint of -s6o Sometimes I suspected that I could see the foreign body, but I never felt sure enough to locate it. Again I supposed that the foreign body might not be imiibedded, but free in the posterior chamber, and that with the watery condition of the vitreous, evident from the rapid and multiple movements of the opacities in that body, the foreign body might change its place, and impinge directly upon the optic disk when he tried to lie down for sleep. I therefore advised sleep in a more or less sitting position, but of no avail. The trouble appeared just the same then as before. Finially, fearing that death fromii exhaustion, or insanity would follow as a result of this continued suffering, but with great nisgivings that the trouble might no longer be local, but central, at the patient's earnest request I enucleated the left, inijured eye on January 26th of this year, nearly I 7 months after the injury. Fully i inch of the trunk of the optic nerve was removed with the eyeball. The section of the nerve appeared normiial. On opening the eye the vitreous was found very fluid, and in the retina, about one optic disk distance toward the nasal side, was found a piece of iron, about one line in length and half a line broad and thick, witlh one edge a little sharper than the other, however, so loos'tly irnbedded in the tissues, that it falls out of itself, showing a slight unevenness in the place where it had lodged. The result of the operation showed that my misgivings were not without cause. For although the pain and photopsy have somewhat diminiished, at this momnent, six mlonths after enucleation, they still persist. The same remedies as before enucleation were also resorted to after this operation, in addition to Fowler's solution, ergot, and iodide of potassiulm, but without any more effect than before. A careful regulation of his diet, and iron and quinine persistently exhibited for quite a long time, have imiiproved his physical appearance, and this, with the fact that I tried to reassure him that the photopsy would slowly disappear when his general health should improve, has probably contributed greatly to the decrease of the nervous excitenment he was laboring under before the operation. But there is still pain in the region of the ophthalmiiic branch of the trigeminus, and in that of the auricularis and occipitalis, with occa-
452
sional rheumatic pains in the limbs, increasing with the slightest cold or exposure. The photopsy is also present, though the flashes are not quite so severe; they are not so extensive or so bright, do nlot last so long as before, so that since a couiple of months he can obtain sleep without any artificial nmeans. The flashes are now always unilateral on the side of the enucleated eye. The vision of the right eye is perfectly normal. The conjunctival sac of the enucleated eye has a perfectly healthy appearance, and pressure with a probe-point on different parts of this membrane does not produce any pain or photopsy. The neuralgic pains still continue to show their nightly exacerbations. I have been unable to account with certainty for the relations between the probable occasioning cause of the trouble, the foreign body within the eye, and the subsequent nervous symptoms. Although the foreign body itself could not be seen, yet its retention within the eyeball could be suspected by tracing its path through cornea, iris, and lens. For this reason I was afraid of the danger of sympathetic ophthalmia, and of this I gave due warning. But I was not prepared for the symptoms as appearing in our case, especially with such severity, and yet without any comiplaint of pain in the eyeball, nor the slightest redness or other visible symiiptomiis of inflamml)ation of the eye; neither was I able to obtain nmuch informiiation in the works on ophthalmic and nervous diseases at my conimand. The only notices on photopsy bearing to some extent upon the subject were in Wharton Jones, 3d American edition, page 300: " Analogous appearances of fiery scintillations, flashes of light, and colored coruscations, occuring spontaneously, are symptomiis of irritation or excitemiient of the optic nervous apparatus-cerebral or ocular-from inflamm'atory congestion of the choroid, as above nmentioned, rather than from inflammlilatory congestion of the retina. As such inflamiimatory congestion may end in amaurosis, so the luminotus and colored spectra are symptonms of incipient amaurosis. They may continue to appear, however, after all visual sensibility is lost." Leber, in Graefe-Saemisch Handbuch der gesammten Augenheilkunde, Vol. V., p. 1046, says that " photopsy can be caused by increased filling of the blood-vessels, inflammation or unknown disturbances of the nervous systemii, as internal cause of irritation, or by much coarser, mechanical influences, dragging or compression by shrinking masses of connective tissuie, calcification, etc. ;" and a little farther: " also by comiipression of the optic nerve from masses of connective tissue in the process of shrinking after injury or after contusion of the stump in enucleation. In
453 some cases this photopsy can becom.e so intense as to produce hallucinations, so that, it may cause anxiety for the mind or life. As a rule, they are entirely remiioved by enucleation of the bulbus or resection of the optic nerve stunmp." Stellwag v. Carion, page 850, mentions the fact of plhotopsy continuing after complete amiiaurosis has set in, and in speaking of causes says, that optic hyperaesthesia appears as a symptom of congestive or inflammatory brain disease, delirium potatorumii, narcotic poisoning, neuralgia of the trigetlminus (Alexandler), etc. These few points, applied to the case reported, would allow of an explanation of the persistency of photopsy in two ways: the first cause was either intraocular, the foreign body witlhin the eye, or the symptom depended upon an affection of the trigenminus, and might have been favored by the presence of that foreign body. In regard to the first explanation, it could be presumiied that the pressure of the foreign body upon the choroid, as stated by Wharton Jones, was the first cause of the photopsy. Although at no timiie while the patient was under my observation, a period of sixteen imonths before enucleation, could any symptoimls of active inflammation be observed, yet some disease of the choroid miiight be suspected from the watery condition of the vitreous humilor and the numerous large opacities within that body. The persistency of the symptomi after enucleation might depend uiponi the same intrinsic action of the brain, by which strong and lasting visual imiipressions are so forcibly implanted in the apparatus of vision, that their afterimages are either continuially present in the field of vision, or at least make their appearance as soon as the patient begins to think of themii. 'This latter condition nmight be highly increased by the great excitability of the centrlal nerve systemii, fromii pain, sleeplessness, and especially from the anxiety cauised by being conscious of the presence of some foreign bo:dy and the possible dangers it miight bring. That such an excitable condition existed in reality is proved by the existence of aural illusion, in the form of the hissing sound accompanying the flashes of light, when they were the worst. In favor of this explanation are the facts that there never was any trouble before the eye was injured, that the impressions were at first entirely, later chiefly unilateral, and that, although by no means removed by the removal of the foreign body, they are decidedly less severe than before. The second opinion would rest especially on the fact of this appearance aftei exposure, simultaneously, or almost so, with pains in
454 the region of the ramus ophthalmicus of the trigeminus, and of their persistency with the pains after enucleation, while it might be strengthened by the negative evidence of absence of visible irritation in the eye. In connection with the trigeminus affection there could be some local hyperaeiimia of the meninges at the base of the cranium, and therefrom pressure on some part of the trunk of the n. opticus. rhe excitability of the cerebral system would work here the saime as with the other explanation. That the persistency of optic hyperaesthesia in this case should depenid upon pressure or dragging from shrinking masses of connective tissue I cannot believe, since the section of the nerve, which as a matter of precaution was removed for quite an extent, appeared healthy. In this respect I believe that my patient would readily submit to resection of the stuimip as advised by Leber, if I could give him the certain promise of relief, which of course I would not dare to do.
