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THEO03ALD: Removal of a Fragment of Steel.
The successful employment of the electro-magnet for the removal of fragments of iron or steel from the interior of the eyeball has become of such frequent occurrence that one hesitates to report such cases unless they present features of especial interest. The fact that in the present instance the foreign body was not removed until the eleventh day after its entrance into the vitreous chamber, and the further fact that in an eye otherwise doomed to destruction nearly normal vision was restored through the magnet's efficient action, seemed features of sufficient interest to justify my presenting a brief report of the case to the Society. C. H., aged 12 years, was first seen on April I, I892, in the out-patient department of the Baltimore Eye, Ear, and Throat Charity Hospital. Six days before, while striking a hatchet with a hammer, a small fragment of steel had been broken from one of them, and had struck his left eye with such force as to cause severe pain and much impairment of vision. The eye exhibited marked conjunctival injection, and, upon closer inspection, a small scar was discovered at the upper and outer corneal margin, and just in line with this a hole in the iris, close to its periphery, of corresponding size. At the anterior pole of the lens, apparently just under the capsule, there was a slight opacity, and with the ophthalmoscope, besides numerous floating opacities in the vitreous, so much diffuse clouding was discovered that the details of the fundus could not be distinguished. Vision was found to be i6/cxxv. There was little room to doubt that the piece of steel was in the eye, although, owing to the clouding of the vitreous humor, its location could not be determined with the ophthalmoscope, and its removal
THEORALD: Pernoval of a Pragment of Steel.
with the electro-magnet was proposed. The instrument not being at hand, the operation was postponed until the next day. On the following day the chloride of silver (' dry cell ') battery with which I had provided myself failed to produce in the magnet (Hirschberg's) any but the most feeble action, and a further postponement was unavoidable. An interval of four days occurred after this before an opportunity to operate upon the eye presented itself. In the meantime the inflammation had not lessened, and iritis had set in. I had decided misgivings as to the likelihood of my efforts to remove the foreign body being successful, after so long an interval from the date of the accident; but it was evident that enucleation at no distant day was the other alternative, and, influenced by this consideration, I did not hesitate to undertake the operation. Chloroform was administered, and antiseptic precautions, consisting in the sterilization of the magnet point and other instruments with boiling water and the flushing of the conjunctival sac with sublimate solution (i to 8,owo), were exercised. A free longitudinal incision was then made through the conjifnctiva, between the external and inferior rectiqmuscles, behind the ciliary body, and the tissues dissected back so as to expose the sclerotic at this point. A Baer's knife was then passed through the sclerotic and inner tunics of the eye, making a longitudinal incision about 4 mm. in length. There was considerable hemorrhage, but the vitreous showed no tendency to escape. Although it had not been possible to locate the foreign body, the greater amount of opacity in the outer and lower quadrant of the vitreous humor and the accessibility of this part of the sclerotic determined the site of the incision. The magnet point, freshly sterilized, was now introduced a short distance into the wound and withdrawn. Examination of its tip showed that the fragment of steel had not been attracted to it. A second, third, and possibly 'a fourth introduction of the point, which was pushed farther into the vitreous chamber and turned in various directions, failed as completely to accomplish the desired result, and I almost concluded that it would be useless to make further attempts. I determined, however, to try once more, and this time probably carried the
THEOBALD: Removal of a Fragment of Steel.
magnet point nearer to the ciliary body than I had done before, and upon withdrawing it was rejoiced to find the bit of steel adhering to it. It was irregular ij shape, having one edge especially sharp, measured about ij mm. in length, i mm. in width, and i mm. in thickness, and weighed but a fraction of a grain. The magnet, which was operated by a single, small Grenet cell (zinc and carbon), was tested before the operation, and found to be capable of lifting a pocket key-ring with four or five keys attached to it. The after treatment of the eye consisted'in the constant application, by means of a bandage and linen pad, of a lotion of opium and boracic acid and the instillatiori of atropia. The improvement in its condition was rapid and uninterrupted, and when the patient left the hospital on April 23d (seventeen days after the removal of the foreign body) the subconjunctival injection had greatly diminished, and the vitreous humor was clearing rapidly; the opacity at the anterior pole of the lens was also less marked. Vision at this time was I6/XLV. The pupillary margin of the iris, at a point corresponding Ovith the wound made in the cornea and iris by the entrance of the foreign body, had formed an adhesion to the lens capsule before the removal of the steel, and this persisted, despite the liberal use of atropia. The case was kept under observation in the out-patient department, atropia only being used, and continued to progress favorably. May 2d V. had improved to i6/xxx. At my request, the patient called at my office a few days since (July 6th). No treatment had been practiced for seven weeks. The difference in the appearance of the two eyes was scarcely perceptible. The pupil of the injured one was not quite circular, and there was just a trace of hyperawmia in the finer conjunctival vessels. In the neighborhood of the wound made through the sclerotic at the time of the operation the hyperaemia was, of course, more marked, and there was still considerable thickening of the episcleral tissues at this point; but this could be seen only when the eye was directed upwards and the lower lid somewhat everted. The lad assured me that
THEOBALD: Removal of a Frag-ment of Steel.
the injured eye gave him no annoyance whatever, and that he felt no dread of light. Upon examining the lens, a very small, well-defined circular spot of- opacity was found just under the capsule at the anterior pole -the only remains of the more diffuse opacity observed in this part of the lens when the case first came under observation. The peripheral wound through the iris was easily found, but was lpss conspicuous than when first discovered. The ophthalmoscope revealed no opacities in the vitreous humor, and showed a normal fundus, except in the region of the sclerotic incision. The site of the latter was indicated by a linear white patch, and just in front of this, and separated from it by an isthmus of normal choroid and retina, there was another spot of atrophy, much smaller and circular in shape, through which the sclerotic could also be distinctly seen. I could make out no evidences of retinal detachment. The small, circular area of atrophy, which was situated between the sclerotic wound and the ciliary body, marked, in all probability, the point where the fragment of steel impinged, and to which it remained attached. If such was the case, the point of the magnet must have been in close proximity to the foreign body each time that it was introduced, and only failed to extract it at first because, as might have been expected after the lapse of so considerable a time from the receipt of the injury, it had become more or less perfectly encapsuled. A test of the vision of the two eyes, both of which were decidedly hypermetropic, showed but a slight difference between them. With +.75s, the left (injured) eye had V. = 20/xxv +, and the right eye, with +.87s, V. = 20/xx-. The possibility of making a further improvement in the vision of each by means of cylinders was not gone into. It is too soon yet, and probably always will be too soon, to say that an eye which has been through the experience this one has will never give trouble, but in the present instance I have little fear as to the future.

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