Gunshot Injuries of the Orbit

Anomalies and Curiosities of Medicine
by George M. Gould, M.D., Walter L. Pyle, M.D.

(Page 13 of 41)

Barkan recites the case in which a leaden ball 32/100 inch in diameter was thrown from a sling into the left orbital cavity, penetrating between the eyeball and osseous wall of the orbit without rupturing the tunics of the eye or breaking the bony wall of the cavity. It remained lodged two weeks without causing any pain or symptoms, and subsequently worked itself forward, contained in a perfect conjunctival sac, in which it was freely movable.

Buchanan recites the case of a private in the army who was shot at a distance of three feet away, the ball entering the inner canthus of the right eye and lodging under the skin of the opposite side. The eye was not lost, and opacity of the lower part of the cornea alone resulted. Cold water and purging constituted the treatment.

It is said a that an old soldier of one of Napoleon's armies had a musket-ball removed from his left orbit after twenty-four years' lodgment. He was struck in the orbit by a musket-ball, but as at the same time a companion fell dead at his side he inferred that the bullet rebounded from his orbit and killed his comrade. For twenty-four years he had suffered from cephalalgia and pains and partial exophthalmos of the left eye. After removal of the ball the eye partially atrophied.

Warren reports a case of a man of thirty-five whose eyeball was destroyed by the explosion of a gun, the breech-pin flying off and penetrating the head. The orbit was crushed; fourteen months afterward the man complained of soreness on the hard palate, and the whole breech-pin, with screw attached, was extracted. The removal of the pin was followed by fissure of the hard palate, which, however, was relieved by operation. The following is an extract of a report by Wenyon of Fatshan, South China: -

"Tang Shan, Chinese farmer, thirty-one years of age, was injured in the face by the bursting of a shot-gun. After being for upward of two months under the treatment of native practitioners, he came to me on December 4, 1891. I observed a cicatrix on the right side of his nose, and above this a sinus, still unhealed, the orifice of which involved the inner canthus of the right eye, and extended downward and inward for about a centimeter. The sight of the right eye was entirely lost, and the anterior surface of the globe was so uniformly red that the cornea could hardly be distinguished from the surrounding conjunctiva. There was no perceptible enlargement or protrusion of the eyeball, and it did not appear to have sustained any mechanical injury or loss of tissue. The ophthalmia and keratitis were possibly caused by the irritating substances applied to the wound by the Chinese doctors. The sinus on the side of the nose gave exit to a continuous discharge of slightly putrid pus, and the patient complained of continuous headache and occasional dizziness, which interfered with his work. The pain was referred to the right frontal and temporal regions, and the skin on this part of the head had a slight blush, but there was no superficial tenderness. The patient had been told by his native doctors, and he believed it himself, that there was no foreign body in the wound; but on probing it I easily recognized the lower edge of a hard metallic substance at a depth of about one inch posteriorly from the orifice of the sinus. Being unable to obtain any reliable information as to the probable size or shape of the object, I cautiously made several attempts to remove it through a slightly enlarged opening, but without success. I therefore continued the incision along the side of the nose to the nostril, thus laying open the right nasal cavity; then, seizing the foreign body with a pair of strong forceps, I with difficulty removed the complete breech-pin of a Chinese gun. Its size and shape are accurately represented by the accompanying drawing. The breech-pin measures a little over three inches in length, and weighs 21 ounces, or 75.6 grams. It had evidently lain at the back of the orbit, inclined upward and slightly backward from its point of entrance, at an angle of about 45 degrees. On its removal the headache was at once relieved and did not return. In ten days the wound was perfectly healed and the patient went back to his work. A somewhat similar case, but which terminated fatally, is recorded in the American Journal of the Medical Sciences of July, 1882."

The extent of permanent injury done by foreign bodies in the orbit is variable. In some instances the most extensive wound is followed by the happiest result, while in others vision is entirely destroyed by a minor injury.

Carter reports a case in which a hat-peg 3 3/10 inches long and about 1/4 inch in diameter (upon one end of which was a knob nearly 1/2 inch in diameter) was impacted in the orbit for from ten to twenty days, and during this time the patient was not aware of the fact. Recovery followed its extraction, the vision and movements of the eye being unimpaired.

According to the Philosophical Transactions a laborer thrust a long lath with great violence into the inner canthus of the left eye of his fellow workman, Edward Roberts. The lath broke off short, leaving a piece two inches long, 1/2 inch wide, and 1/4 inch thick, in situ. Roberts rode about a mile to the surgery of Mr. Justinian Morse, who extracted it with much difficulty; recovery followed, together with restoration of the sight and muscular action. The lath was supposed to have passed behind the eyeball. Collette speaks of an instance in which 186 pieces of glass were extracted from the left orbit, the whole mass weighing 186 Belgian grains. They were blown in by a gust of wind that broke a pane of glass; after extraction no affection of the brain or eye occurred. Watson speaks of a case in which a chip of steel 3/8 inch long was imbedded in cellular tissue of the orbit for four days, and was removed without injury to the eye. Wordsworth reports a case in which a foreign body was deeply imbedded in the orbit for six weeks, and was removed with subsequent recovery. Chisholm has seen a case in which for five weeks a fly was imbedded in the culdesac between the lower lid and the eyeball.

Foreign bodies are sometimes contained in the eyeball for many years. There is an instance on record in which a wooden splinter, five mm. long and two mm. broad, remained in the eye forty-seven years. It was extracted, with the lens in which it was lodged, to relieve pain and other distressing symptoms. Snell reports a case in which a piece of steel was imbedded and encapsulated in the ciliary process twenty-nine years without producing sympathetic irritation of its fellow, but causing such pain as to warrant enucleation of this eye. Gunning speaks of a piece of thorn 5/8 inch long, imbedded in the left eyeball of an old man for six years, causing total loss of vision; he adds that, after its removal, some improvement was noticed.

Williams mentions a stone-cutter whose left eye was put out by a piece of stone. Shortly after this his right eye was wounded by a knife, causing traumatic cataract, which was extracted by Sir William Wilde, giving the man good sight for twelve years, after which iritis attacked the right eye and produced a false membrane over the pupil so that the man could not work. It was in this condition that he consulted Williams, fourteen years after the loss of the left eye. The eye was atrophied, and on examination a piece of stone was seen projecting from it directly between the lids. The visible portion was 1/4 inch long, and the end in the shrunken eye was evidently longer than the end protruding. The sclera was incised, and, after fourteen years' duration in the eye, the stone was removed.

Taylor reports the removal of a piece of bone which had remained quiescent in the eye for fourteen years; after the removal of the eye the bone was found adherent to the inner tunics. It resembled the lens in size and shape. Williams mentions continual tolerance of foreign bodies in the eyeball for fifteen and twenty-two years; and Chisholm reports the lodgment of a fragment of metal in the iris for twenty-three years. Liebreich extracted a piece of steel from the interior of the eye where it had been lodged twenty-two years. Barkar speaks of a piece of steel which penetrated through the cornea and lens, and which, five months later, was successfully removed by the extraction of the cataractous lens. Critchett gives an instance of a foreign body being loose in the anterior chamber for sixteen years. Rider speaks of the lodgment of a fragment of a copper percussion cap in the left eye, back of the inner ciliary margin of the iris, for thirty-five years; and Bartholinus mentions a thorn in the canthus for thirty years. Jacob reports a case in which a chip of iron remained in the eyeball twenty-eight years without giving indications for removal. It was clearly visible, protruding into the anterior surface of the iris, and although it was rusted by its long lodgment, sight in the eye was fairly good, and there was no sign of irritation.

Snell gives an instance in which a piece of steel was imbedded close to the optic disc with retention of sight. It was plainly visible by the opthalmoscope eighteen months after the accident, when as yet no diminution of sight was apparent. Smyly speaks of a portion of a tobacco pipe which was successfully removed from the anterior chamber by an incision through the cornea. Clark mentions a case in which molten lead in the eye caused no permanent injury; and there are several cases mentioned in confirmation of the statement that the eye seems to be remarkably free from disastrous effects after this injury.

Williamson mentions eyelashes in the anterior chamber of the eye, the result of a stab wound of this organ.

Contusion of the eyeball may cause dislocation of the lens into the anterior chamber, and several instances have been recorded. We regret our inability to give the reference or authority for a report that we have seen, stating that by one kick of a horse the lenses of both eyes of a man were synchronously knocked through the eyeballs by the calkins of the horseshoe. Oliver mentions extraction of a lens by a thrust of a cow's horn.

Lowe speaks of rupture of the anterior capsule of the lens from violent sneezing, with subsequent absorption of the lenticular substance and restoration of vision. Trioen mentions a curious case of expulsion of the crystalline lens from the eye in ophthalmia, through the formation of a corneal fissure. The authors have personal knowledge of a case of spontaneous extrusion of the lens through a corneal ulcer, in a case of ophthalmia of the new-born.