CHAPTER IV. DISPLACEMENTS OF THE EYEBALL (Part 1)

CHAPTER IV. DISPLACEMENTS OF THE EYEBALL Next in order we observe whether the eyeballs occupy their nor- mal positions in the orbits and maintain their proper relations to each other. An eyeball which occupies an abnormal position as a whole in the orbit is displaced; when the visual axis of one is not parallel with that of the other the eye is said to deviate. Dis- placement of an eye is almost invariably associated with deviation, but deviation often is met with without displacement, so the two will be considered separately. One orbit may be placed higher than the other and produce a vertical displacement of the eyes with reference to each other, but this is not included because each globe occupies its normal position in its own orbit. At the same time such a condition as this must not escape notice, as it is a serious cause of eyestrain. ENOPHTHALMOS A sunken eye, its upper lid drooping from lack of support, is in the condition of enophthalmos. The eyes recede a little when the lids are closed tightly, or are pressed upon, but this physiological recession is not included. If we see no eye when we lift a drooping lid, we have to learn from the history whether it was absent at birth, or has been enucleated, though the latter may be indicated by the presence of scars. If the eye is abnormally small, with no signs of injury or disease, and the condition is congenital, the case is one of microphthalmos. Should there be a history of inflammation or injury of a previously good eye, and the globe be both small and deformed, it is atrophic. It is only when the eyeball appears to be of normal size that we speak of enophthalmos, and then we have to inquire into the cause. Bilateral enophthalmos appears in atrophy of the orbital fat, whether caused by disease or old age; in these cases the condition and the cause are recognized readily. A slight enophthalmos of one eye sometimes is seen during an 62 DISPLACEMENTS OF THE EYEBALL 63 attack of migraine, and may be caused in very rare cases by a spasm of all four recti. Ball says that three cases have been re- ported in which the eye receded when the lids were separated forci- bly and returned to place when the force was removed. When a patient presents a slight degree of enophthalmos of one eye with a myosis that is not affected by cocaine, and redness and warmness, or perhaps abnormal paleness of the same side of the face, some lesion implicates the cervical sympathetic on the same side. This may be a swelling of the thyroid, a tumor in the neck, posterior mediastinum, or upper part of the chest, an aneurysm of the carotid, an injury of the neck, an excision of the superior cervical ganglion, a traumatic paresis of the brachial plexus, or syringomyelia. A very great enophthalmos of one eye is nearly certain to be associated with scars about the orbit, for almost always the cause is a violent traumatism. The patient presents a deeply retracted eye over which the lids are sunken, and the palpebral fissure narrowed, so that he looks much as though he were wearing an artificial eye. The displacement may be directly backward, or downward with a deviation upward. The mobility is much impaired. The vision may be lost, or it may be good, and in the latter case the patient has diplopia, at least when the upper lid is lifted. Quite a number of theories have been advanced to account for this displacement when it occurs as the result of a direct traumatism, but no one is universally satisfactory, so it is probable that the lesions which cause the eyeball to recede are not the same in all cases. The his- tory of the removal of a tumor from the orbit furnishes a sufficient explanation, and so does one of an orbital cellulitis, as this may leave cicatricial bands that draw the eye back by their contraction. Retraction of the eyeball into the orbit durmg the movements of the eye is one of the symptoms of a rare syndrome caused by a congenital deficiency of certain extrinsic muscles, especially the externus, or by tense cicatrices that furnish an unyielding resist- ance to the endeavors of other muscles to turn the eye in the opposite direction. EXOPHTHALMOS The essential feature of exophthalmos is that the entire eyeball is projected forward in the orbit. When the anterior portion pro- jects while the eyeball as a whole maintains its normal position, as 64 DIAGNOSIS FROM OCULAR SYMPTOMS in infantile glaucoma, in some cases of myopia, and when the mar- gins of the orbit are developed imperfectly, a fault that is particu- larly noticeable when it is confined to one side of the face, the prominence of the eyeball does not constitute exophthalmos. A slight amount of movement forward on the part of the eyeball seems to be physiological, for Birch-Hirschfeld has proved by photographs that our eyeballs protrude a little when we stoop, and when we open our lids widely, but this again is not meant when we speak of exophthalmos. A displacement forward is produced mechanically by a relaxa- tion of the tissues that hold the eye back, or by a reduction of space within the orbit through an increase of its contents, or an encroach- ment upon this space by the bony walls. The physiological pro- trusion of the eyes may be increased by the congestion caused by compression of the facial veins, and such a congestion may produce a distinct exophthalmos when the jugular veins are compressed in the neck. The increase of the orbital fat sometimes makes the eyes of corpulent persons very prominent, but unless the promi- nence is considerable it is of little consequence. Exophthalmos is congenital in certain deformities of the skull in which the orbit is shortened and the eyeball pushed forward; in these cases it varies in degree according to the amount of deformity of the orbit, it may be slight or very great, but it is irreducible and not likely to be progressive. The eyeball may be displaced not only forward, but also upward, downward, or in any lateral direction, according to the location of the force which displaces the contents of the orbit. It is important to note the extent and direction of the displacement, whether it is reducible or not, whether its progress has been rapid or slow, the motility of the affected eyeball and of the lids, and the presence or absence of any signs of inflammation. A slight protrusion can be detected when the extrinsic muscles of the eye are paralyzed, and is more apparent when the affection is confined to one eye alone, but it is very subordinate to the other symptoms and adds nothing to help us in diagnosis. It always is slight and is never productive of serious consequences. <A similar slight protrusion often is to be seen after a free tenotomy of one of the muscles, especially of the internal rectus of one eye, when the history and perhaps a scar in the conjunctiva is likely to furnish the explanation. DISPLACEMENTS OF THE EYEBALL 65 Well marked exophthalmos usually indicates a serious condi- tion. It may be produced by certain affections of the nervous system, usually is present in exophthalmic goiter, and above all is the cardinal symptom of nearly all of the diseases that occur in the orbit. We note the condition of the surrounding tissues, any general symptoms that may be present, the presence or absence of any swelling or sign of inflammation in the lids or face, intro- duce the tip of a finger within the margin of the orbit and feel about for any point of abnormal resistance or tenderness, investi- gate the condition of the nose, transilluminate the accessory sinuses, and have roentgenographs taken. Any or all of these measures may be necessary to determine the diagnosis in any particular case, but sometimes the associated symptoms suffice to direct our atten- tion to a specific cause. A slight exophthalmos associated with dilatation of the pupil and increased perspiration and pallor of the same side of the face, indicates that some lesion is irritating the sympathetic nerve on that side. Exophthalmic Goiter The combination of exophthalmos, usually bilateral, widening of the palpebral fissure, decreased frequency in winking, a retarded movement of the upper lid when it should accompany the eye in its downward movement, and a peculiar tremor of the lids when gently closed, with tachycardia, enlargement and palpitation of the heart, a feeling of oppression, pulsation of the large arteries in the neck, sometimes a rhythmic concussion in the head, a swelling of the thyroid, over which a thrill may be felt and a roar heard, and a tremor of the hands when they are held out with their palms down, forms the clinical picture of exophthalmic goiter, or Graves’s disease. Other symptoms that may be mentioned are nervousness, mental depression, apprehension, excessive sweating, emaciation, weakness and pain in the limbs, brittleness of the nails, partial alopecia including the brows and lashes, lacrimation, conjunctivitis, and insufficiency of convergence. The tachycardia, exophthalmos, and enlarged thyroid are spoken of usually as the three cardinal symptoms, but the only one of them that can be said to be present in all cases is the tachycardia, and it is a curious commentary on our nomenclature that exophthalmic goiter may exist without ex- ophthalmos, without goiter, or without either. We feel almost 66 DIAGNOSIS FROM OCULAR SYMPTOMS compelled to call it Graves’s disease, after the Englishman who first described it as an individual affection, as is done in Great Britain. Germans call it Basedow’s disease from the name of their countryman who amplified Graves’s description some years later. Hemorrhage into the Orbit Sometimes an exophthalmos appears suddenly together with ecchymoses in the lids and beneath the bulbar conjunctiva, and we meet with a firm resistance when we try to press the eyeball back. A hemorrhage has taken place behind the eyeball, usually as the result of traumatism. If a severe contusion has fallen upon the face in the vicinity of the eye, we conclude that there is a fracture of the wall of the orbit, or that blood vessels within it have been lacerated. A penetrating wound may produce the same result. The amount of exophthalmos, the direction in which the eyeball is displaced, and the degree to which its movements are re- stricted, vary in accordance with the position and extent of the hemorrhage. When the contusion fell upon some part of the cranium we infer from these symptoms that it produced a frac- ture of the base of the skull. The same local condition is occasion- ally produced without traumatism, in persons who have brittle blood vessels, by a rupture of the orbital vessels during straining, stooping, or coughing, and a few cases are on record in which even such a slight actuating cause was denied. The hemorrhage may be altogether out of proportion to the traumatism when the patient is hemophilic. The consequences to the eye of a retrobulbar hemor- rhage may be serious through the pressure exerted on the optic nerve, the interference with nutrition, and the exposure of the cornea to the air when the exophthalmos is so great that the lids cannot close over it, but an immediate blindness tells us almost with certainty that the optic nerve itself has been wounded. Emphysema of the Orbit Sometimes a rather similar picture is seen after a contusion in the region of the orbit in which the lids, aside perhaps from some ecchymoses, are pale, swollen, and closed over the exophthalmic eyeball, which may be pressed back somewhat into the orbit. Per- cussion over the globe elicits a tympanitic note. This is an emphy- sema of the orbit. It indicates that an opening has been made in DISPLACEMENTS OF THE EYEBALL 67 the bony wall which communicates with one of the adjacent air chambers and permits the entrance of air. We do not obtain the feeling of crepitation under our fingers that we do in emphysema of the lids, unless the air has entered both the orbit and the lids, as is frequently the case. Luxation of the Eye When an eye has been luxated by the introduction of a foreign body into the orbit the cause is evident, as a rule. Occasionally such a mutilation is self-inflicted in insanity by passing the finger deep into the orbit. There is little chance for error in any of the above mentioned conditions, but in others the keenest powers of observation and deduction may try in vain to determine the exact cause of an ex- ophthalmos prior to operation. In the majority of cases in which a protrusion of the eyeball has developed as it were spontaneously it has been caused by a tumor, yet sometimes we have to deal in- stead with a syphilitic or tuberculous disease. When a tumor is present it is well for both the patient and the surgeon if we can determine before operation whether it is malignant or benign, and if benign whether it is vascular, cystic, bony, or fibrous, whether it is fixed or freely movable, and where it is situated, for all of these things bear upon the method of intervention to be chosen. We should feel humiliated if, after performing Kronlein’s opera- tion, we found that the tumor was on the opposite side of the orbit, was one that could have been removed through an incision in the conjunctiva, or was an ivory exostosis from the frontal sinus which must be approached in a different way, and it is only less mortify- ing to ascertain, after we have entered upon some other form of operation, that we should have recognized that a resection of the outer part of the wall of the orbit was necessary. Exophthalmos Due to Syphilis and Tuberculosis If a patient with exophthalmos of unknown origin gives a, his- tory, or presents clinical signs of syphilis, a Wassermann or a Noguchi test should be made, and an energetic antiluetic treatment tried. Neither a positive Wassermann, nor indubitable evidence of active syphilis, suffices for a diagnosis of syphilitic disease of the orbit, for any kind of a tumor may develop here in a syphilitic as 68 DIAGNOSIS FROM OCULAR SYMPTOMS well as in anyone else. The only positive proof is the rapid sub- sidence of the exophthalmos under antisyphilitic treatment. Tuberculosis of the retrobulbar tissues is met with very rarely, and then in elderly people. Positive differentiation from a tumor is not yet possible, but the probability of such a diagnosis is en- hanced by the presence of tuberculous lesions in or about the eye, as well as by a local reaction to the tuberculin test. Exophthalmos Caused by Tumors We need to learn from the history the nature of the first signs of trouble and when they were first noticed. Often the protrusion of the eye is the first thing observed, but sometimes this is preceded by a persistent headache, perhaps followed by a deterioration of vision. We ascertain whether there was an antecedent traumatism, and whether the patient is suffering from some disease, like leu- cocythemia, in which the development of orbital tumors is sympto- matic, or, if the appearance of the patient is such as to suggest this, we have an examination made of the blood. We notice whether the eyeball projects axially from the orbit, or is displaced in any other direction, and we measure this displace- ment, as it may give us a clue to the size and location of the tumor. Then we introduce the tip of a finger as deeply as possible within the margin of the orbit, starting at the place indicated as the prob- able site by the inclination of the eyeball, and feel for an object that presents an abnormal resistance. If we find such an object we try to determine its consistency, whether it is hard, firm, or soft, to ascertain whether it is fixed or movable, situated deeply or super- ficially, and, so far as we may, its size and structure. We learn much that is of service in this way. To take a rare but very plain example, if the exophthalmos has developed very slowly, was pre- ceded for a long time by persistent frontal headache, if the brow is protuberant and has slowly grown more so along with the ex- ophthalmos, if the eyeball is displaced forward, downward, and outward, and if the finger beneath the upper, or upper and inner portion of the margin of the orbit impinges on a hard, immovable object, it is almost certain that the patient has an ivory osteoma growing from the junction of the ethmoid and frontal bones, which distends the frontal sinus and pushes its processes toward or into the neighboring cavities of the orbit, the nose and the cranium. DISPLACEMENTS OF THE EYEBALL 69 Very slow growth increases the probability that the tumor is benign; very rapid growth strongly indicates that it is malignant. The history of antecedent symptoms referable to the development of a tumor in one of the accessory sinuses, the nose, or the adjacent part of the cranium, render it likely that the orbit is involved secondarily. If the eyeball is displaced downward the tumor probably is above, though not necessarily so, for if it happens to be situated on the floor of the orbit in such a place that it presses the posterior end of the eyeball upward, the anterior end will be tilted down so as to produce the same picture. The tip of the finger can be introduced quite a distance into the orbit, carrying the lid before it, especially when the eyeball has been pushed aside, and the feeling when it impinges on a hard, immovable substance is unmistakable. The same