CHAPTER IV. DISPLACEMENTS OF THE EYEBALL (Part 2)

sense of touch tells us when the body feels tense and firm, or soft and fluctuating. By pressing upon it we learn whether it is movable, or fixed to the periosteum. If we can move it about we conclude that it originated from the soft tissues in the orbit; if it is movable with the eyeball we know that the two are intimately connected. If fluctuation can be detected, it is a rather superficial cyst which may contain serum, lacrimal fluid, echinococcal fluid, cerebrospinal fluid, or blood encapsulated after a hemorrhage. If it is in the upper inner angle of the orbit it may be an encephalocele, or a meningocele at the junction of the frontal, superior maxillary, ethmoid and lacrimal bones, or a distended mucous bursa of the trochlea; the hernize cerebri are congenital, the distended bursa usually is acquired. The differentiation can be made in all of these conditions by aspiration and examination of the fluid. It is unnecessary to give in detail the chemical and cytological properties by which we distinguish serum, blood, lacrimal fluid, and cerebrospinal fluid, but it may be well to say that when we find a fluid that has a high specific gravity and contains hydrochloric and succinic acids, the cyst is a hydatid, which usually is attended by pain and inflammation. Cysts that are situated so deeply in the orbit as to be beyond the reach of the exploring finger are apt to produce a nearly or quite axial exophthalmos. The presence of a blood cyst may be inferred rather than diagnosed from a history of a retrobulbar hemorrhage in the distant past, after which the exophthalmos decreased somewhat, but never passed away entirely. An en- cephalocele or meningocele may protrude through the superior 70 DIAGNOSIS FROM OCULAR SYMPTOMS orbital fissure or the optic foramen, and as long as such a cyst, which is congenital, remains in open communication with the brain cavity, the pulsation of the brain will be communicated to it and may be transmitted by it to the exophthalmic eyeball. The dif- ferentiation of this condition will be considered under pulsating exophthalmos. A firm, slowly growing tumor in the upper outer angle of the orbit may be a swollen lacrimal gland, or a dermoid. This is the favorite situation of the latter, though it may occur elsewhere. If the mass can be pressed back beneath the margin of the orbit it is the gland, perhaps containing a tumor, but if it cannot the probability is that it is a dermoid. In the latter case we try to ascertain by manipulation whether it extends far back into the orbit and will require a Kronlein operation for its removal, or can be shelled out like the lacrimal gland through an incision in the conjunctiva. A firm, freely movable tumor, that has grown very slowly, situ- ated anywhere between the eyeball and the wall of the orbit, is either a benign neoplasm or a fibrosarcoma; the differentiation cannot be made clinically. An optic nerve with its sheath dis- tended with fluid may bend upon itself and form a knuckle which may give the same sensations to the exploring finger as a fibroma from the muscular or connective tissue, as well as displace the eye- ball in the same manner. Such a case forms an exception to the rule that tumors of the optic nerve displace the eyeball nearly or quite axially, which is one of the chief diagnostic features of these growths. When exophthalmos appears early, increases slowly without pain, and is directly forward, we believe it to be caused by a tumor of the optic nerve, which usually is benign. An addi- tional symptom is that, as a rule, the eye becomes blind at an early age, with symptoms of optic neuritis followed by atrophy. Exophthalmos may affect either one or both eyes in acromegaly; it is uncertain whether it is caused by a proliferation of fat in the orbit, or by compression of the cavernous sinus. It is seen very rarely in hydrophthalmos. If the exophthalmos is bilateral, and tumors can be felt in both orbits, we must think of lympho- mata, or of Mikulicz’s disease. A rapidly growing tumor of the orbit probably is malignant. A carcinoma is seen very seldom and usually starts in the neigh- boring tissues, the lids, the lacrimal gland, or the accessory sinuses, DISPLACEMENTS OF THE EYEBALL 71 especially the antrum. It can be diagnosed clinically only from the presence of carcinoma elsewhere. Sarcoma, on the contrary, is quite common, starts from every possible tissue in the orbit, and appears at any age. All forms are met with, ranging from the rapidly growing and very malignant small cell variety to the slowly growing fibrosarcoma, which is hard to distinguish clinically from a benign tumor for a long period in its course. Pigmentation usually is absent. When tumors have grown very rapidly in both orbits we may suspect the rare and malignant chlorosarcoma or chloroma, and this suspicion becomes certainty if they have a greenish hue when seen through the conjunctiva. It seems almost incredible that a considerable degree of exoph- thalmos can develop and persist, and yet nothing be found to ex- plain it after an exploratory operation. Such an occurrence might be referred to the unwitting evacuation of a cyst if the exploration were made through the conjunctiva, or by means of an enucleation of the eyeball, but Roemer pictures in his textbook a case in which the eye was quite protuberant and dislocated downward, but no tumor was found after he had performed Kréonlein’s operation. In a similar case of rapidly advancing axial exophthalmos in a little child I resected the outer wall of the orbit, but could find nothing except an oedematous condition of all of the tissues. Mi- croscopical examination of these tissues proved it to be a case of Pulsating Exopnthalmos ‘When a patient presents a red, cedematous upper lid, its skin full of dusky, dilated veins, hanging tensely down over an exoph- thalmic eyeball, the conjunctiva of which is chemotic and shows many dilated veins, if we can feel a rough thrill and pulsation when we place a hand on the protruding eye, and can hear with the stethoscope a blowing murmur that is audible to the patient and is the source of much discomfort, we say that he has a pulsating exophthalmos. The vision may not be affected, or it may be destroyed as the result of an ischemia of the retina, caused by the compression of the central artery, and the consequent atrophy, or of a venous engorgement of the papilla and retina, which is often accompanied by retinal hemorrhages, The eye pulsates synchronously with the heart. Such a pulsating exophthalmos as this is due to an arteriovenous aneurysm of the carotid and the cavernous sinus, or an aneurysm of the carotid within the sinus, 72 DIAGNOSIS FROM OCULAR SYMPTOMS which may be caused in two ways—with and without traumatism. As a rule, it is caused by a fracture of the skull, occasionally by a gunshot wound, and considerable time may elapse, perhaps months, after the injury before the picture develops. Less often a person who is stooping or coughing notices a cracking sound, feels a severe pain, and has a pulsating exophthalmos appear quickly. This has been observed in elderly people and in pregnant women, but can happen only when the wall of the carotid is not normal. In both of these varieties the eyeball recedes when the carotid of the same side is compressed, the movements of the globe are more or less limited, and frequently one or more of the muscles are paralyzed, giving rise to a deviation of the eye. A pulsating exophthalmos in which there are few, if any, signs of venous engorgement in the lids or conjunctiva, no thrill is felt, and no murmur heard through the globe, may be due to a meningocele or encephalocele in the back part of the orbit which is in open communication with the brain, to a vascular tumor that receives pulsations from some artery, like an aneurysm of the ophthalmic artery, or to a solid tumor so placed as to receive and transmit arterial pulsation. If the condition is congenital and there has been no traumatism, the trouble probably is a hernia of the brain, either a meningocele or an encephalocele, into the back part of the orbit, and this is to be thought of first when the patient is a child. When the condition has been acquired by an older patient, we have to deal with either a solid or a vascular tumor, and to differentiate between these we inquire into a possible history of traumatism, which may have been of such a nature as to injure the retrobulbar blood vessels, and investigate the vascular system for any disease that might explain the formation of an aneurysm. In the absence of these we may conclude that a solid tumor is present, but we cannot be positive in all cases. Exophthalmos Caused by Vascular Trouble Other vascular troubles may cause an exophthalmos that does not pulsate. An angioma may start in the lid and extend slowly into the orbit until the eye is made to protrude, or one may form deep in the orbit, frequently in the muscle funnel, where it often is congenital. The former is not hard to recognize, but the latter may be very difficult. ‘The exophthalmos varies in degree from time to time and is increased by any strong emotion, or by stoop- DISPLACEMENTS OF THE EYEBALL 73 ing, unless the angioma happens to be encapsulated, so the pres- ence of this symptom leads us to suspect angioma at once. The finger palpating between the eyeball and the orbit may fail to detect any growth, or it may impinge on a soft, cushiony, elastic mass that does not pulsate. If the tumor has extended forward far enough to be visible externally, it forms a doughy, purplish swelling that partially closes the lids over the eye. The exophthal- mos is not great, and is not wholly reducible by pressure, though in all vascular tumors the eyeball can be pressed back more or less into the orbit. If the exophthalmos is bilateral we should look for an aneurysm of the basilar artery. Very rarely we meet with a patient in whom one eyeball pro- trudes unduly when he stoops, and returns to its normal position as soon as he holds his head erect. This is supposed to be due to a varicose dilatation of the veins of the orbit and is called an intermittent exophthalmos. Inflammatory Exophthalmos A sudden protrusion of the eye with pain, fever, swelling and redness of the upper lid, may be a symptom of such widely dif- ferent conditions as a thrombosis of the retrobulbar veins and of the cavernous sinus, periostitis of the walls of the orbit, inflamma- tion of one or more of the accessory sinuses, orbital cellulitis, tenonitis, and panophthalmitis. Orbital Cellulitis When a patient is prostrated suddenly with fever, the eyeball projects directly forward in the axis of the orbit and is more or less immobile, the lids are swollen and the upper one hangs down over the eyeball, the conjunctiva is chemotic, and the dull pain is increased by attempts to move the eye, as well as by pressure upon it, but no points of marked tenderness can be found within the margin of the orbit, and the refractive media of the eye are clear, he has an orbital cellulitis. Its cause may have been a slight, or a severe traumatism that has lodged a foreign body in the orbit. Quite a number of cases are known in which a child has fallen on a sharp stick, or a pointed pencil, in such a way that a portion of the stick was driven through the conjunctiva into the orbit and broken off, where it was hidden and left no 7A DIAGNOSIS FROM OCULAR SYMPTOMS visible wound or other traces, but soon caused a fatal cellulitis unless it was found and removed. Cellulitis may be caused by mumps, tonsillitis, puerperal fever, and other infectious diseases, by a purulent dacryocystitis, a thrombophlebitis of the facial veins, or a panophthalmitis, but in sixty per cent. or more of the cases it originates from an inflammation of one of the accessory sinuses, and then the direction in which the eyeball is displaced is of much help in determining which sinus or sinuses contains the primary disease. Exophthalmos has been observed in rare cases of actinomycosis, glanders and anthrax of the orbit. If an acute exophthalmos appears after a penetrating wound of the orbit, associated with stiffness of the neck, convulsions, facial palsy, and spasms of the muscles of the throat, we know the cause to be tetanus. An acute exophthalmos may be symptomatic of an abscess in or about the lacrimal gland, or of an acute dacryoadenitis, the diagnosis of which has been considered under the lacrimal organs. Orbital Periostitis An acute exophthalmos, usually with a lateral displacement, associated with fever, pain, perhaps nausea and vomiting, diplopia, inability to move the eye in certain directions, and a firm or fluctuating, very tender, node on the wall of the orbit beneath a circumscribed redness and swelling of the lid, is indicative of a periostitis at the point of tenderness. Such a periostitis may develop during or after an attack of some infectious disease, such as measles, scarlet fever, typhoid fever, influenza, or tonsil- litis, or it may be caused by traumatism. An abscess of the retrobulbar tissue, or an abscess in the zygomatic fossa, must be taken into account after all other causes have been excluded. In the great majority of cases we have to consider whether it is due to syphilis, tuberculosis, or an empyema in one of the eee sinuses. A periostitis of the margin of the orbit does not produce ex- ophthalmos unless it extends back of the tarso-orbital fascia, but it calls for a thorough investigation of the organism. If it is situated on the upper margin the chances are that it is syphilitic; if it is on the lower or outer, it probably is tuberculous. Both syphilitic and tuberculous periostitis of the orbit are rare, but both may extend back of the tarsoorbital fascia, and then exoph- DISPLACEMENTS OF THE EYEBALL 75 thalmos is added to the symptoms. Syphilitic periostitis may appear anywhere on the walls of the orbit, both in adults who have acquired the disease, and in children in whom it is hereditary, so it is well to try the effect of an energetic antisyphilitic treatment when a patient who gives a history or clinical signs of syphilis has a periostitis of the orbit; if the symptoms abate immediately the diagnosis may be considered settled. A tuberculous _periostitis usually appears in children or young people, frequently after a contusion, and causes exophthalmos very rarely. Its clinical pic- ture differs materially from that of tuberculosis of the retrobulbar tissue, which likewise is rare, but appears in elderly people, develops slowly, and is hard to differentiate from a retrobulbar tumor. In most cases of exophthalmos due to a periostitis we find the cause of the latter to be in one of the accessory sinuses. If the tender point is just within the upper inner angle of the orbit, an empyema of the frontal sinus is suggested, if it is over the lacrimal bone we think of the ethmoid, if it is within the lower margin the maxillary sinus probably is the seat of the trouble. A catarrhal inflammation in these sinuses, or a mucocele, rarely excites inflam- mation in the orbit, while empyemata do so frequently. A mucocele bulges out the wall of the sinus in the direction of least resistance, encroaches on the space of the orbit, and pro- duces.a slowly developing exophthalmos in the same direction as when a periostitis is formed, but the inflammatory symptoms are slight or absent. A mucocele may be difficult to differentiate because no pus is to be found in the nose, and its contents do not present the same obstacle as pus to the passage of light, or of the X-rays. Usually the only ocular symptoms are a noninflam- matory exophthalmos with its attendant diplopia, but these are absent in mucocele of the sphenoidal sinus. The exophthalmos induced by disease of the frontal sinus is forward, downward, and outward; that occasioned by an ethmoiditis is forward, outward, and slightly downward; that produced by an inflammation of the antrum is forward and upward. The direc- tion of the exophthalmos together with the locality of a tender point or swelling at the places above indicated, is an excellent guide to the site of the primary inflammation, but alone is not sufficient for a diagnosis; the nose must be inspected, the sinuses trans- illuminated, and roentgenographs taken, for these may exclude the sinuses even when all the other symptoms point in their direction. 76 DIAGNOSIS FROM OCULAR SYMPTOMS In a case of abscess in the zygomatic fossa these symptoms may lead us to believe that we have to deal with an empyema of the antrum or of the ethmoid when these cavities are free from disease. The same may be true of an orbital cellulitis that starts from the sphenoidal sinus, or the posterior ethmoidal cells, in which the only distinctive point is the early and grave involvement of the optic nerve; but as this may happen in a cellulitis from other causes our best reliance from which to learn the primary seat of the trouble is the roentgenograph. Diseases of the posterior ethmoidal cells and sphenoidal sinus rarely cause external ocular symptoms, but are apt to manifest themselves by visual disturbances. Sometimes an optic neuritis, or an occlusion of the vessels, may be visible with the ophthal- moscope, but often the fundus appears to be perfectly normal. Yet even in these cases we may be able