the other hand, the diseased gland should be excised, otherwise, by long-continued pressure on the eyeball, it may ultimately lead to its destruction. per Excision of the Lachrymal Gland is thus Excision of formed:-An incision is made about an inch and a lachrymai gland. half long, through the upper lid, parallel to the outer two-thirds of the supra-orbital ridge; the edges of the wound being separated, and the cellular tissue divided, Operation. the gland is readily exposed, together with its accessory lobe, and it may then be separated from its attachments with the handle of the scalpel and removed. Clots of blood should be carefully washed out of the wound, and its edges brought together with sutures, cold-water dressings being subsequently applied. method. Mr. J. Z. Laurence directs that, in excising the Another gland, a transverse incision of three-fourths of an inch in length should be made into the orbit, over the upper and outer third of the orbital ridge; he then divides the external commissure of the lids with scissors; and by connecting the outer ends of the two incisions, forms a triangular flap, which is thrown up. The lachrymal gland is thus easily exposed, secured by a sharp hook, drawn forwards, and removed. The edges of the wound are then united by sutures. The linear scar of the incision is subsequently inappreciable, being lost in the folds of the upper eyelid.* The extent of the incision will of course vary with the size of the tumour to be removed. If the eyeball has been forced from its socket by the morbid growth, a pad should be applied over the lids subsequently to the operation, so as to retain it in its natural position till the tissues have retracted to their normal extent. * Medical Times and Gazette, Sept. 1, 1866, p. 231. G 2 CHAPTER IV. CONTU SIONS. eye." Treatment. DISEASES OF THE EYELIDS. Wounds and injuries- Inflammation- Ulceration- sis. WOUNDS AND INJURIES. CONTUSIONS OF THE EYELIDS.-A blow on the edge of the orbit or eyelids is apt to be followed by considerA "black able swelling and ecchymosis of the part, a "black eye" being the result. We are frequently consulted in such cases, in order, if possible, to prevent the disfigurement caused by a bruise in this conspicuous part of the face. If the patient applies to us soon after the injury has been inflicted, and before any considerable amount of blood has become effused into the loose cellular tissue of the part, we may generally prevent any further ecchymosis by the application of a piece of lint soaked in a mixture of tincture of arnica and water (one part of the former to eight of the latter), which should be kept constantly applied to the eye; "it promotes the absorption of effused blood, prevents discoloration, and relieves pain and stiffness;"* or a solution of muriate of ammonia, acetate of lead, or ice may be used in the same way; but under any circumstances the eyelids should be kept closed and at Arnica, Rest. rest. Ecchymosis of the eyelids may be the remote effect "Elements of Materia Medica," by W. Frazer, 2nd edit., p. 278. in facture of a far more serious injury, and thus it may become Ecchymosis a very important indication in cases of blows on the of the lids head, where one or more of the bones forming the of the walls of the orbit have been fractured. In these cases, skull, the position of the primary injury and the absence of swelling of the lids, together with the gradual advance of the ecchymosis, point but too clearly to the serious nature of the lesion that has taken place, the blood having been effused into the ocular conjunctiva and cellular tissue of the eyelid from the seat of fracture. It follows, therefore, that if the lower wall of the orbit is fractured, the ecchymosis will first be noticed beneath the conjunctiva of the lower hemisphere of the globe of the eye, and in the lower eyelid; and conversely, in cases where the orbital plate of the frontal an aid to bone has been fractured, it will appear in the upper lid and conjunctiva. In instances of this description, the ecchymosis is but a very small matter, and is worthy of attention simply as throwing some light on what might otherwise be an obscure case of injury. diagnosis. WOUNDS OF THE EYELIDS.-In simple incised wounds WOUNDS. of the lids, the edges of the wound must be brought into apposition with one or more fine silk or silver- Simple. wire sutures, and cold-water dressing subsequently applied. The sutures may be removed after two or Sutures three days; but until then, it is advisable to close the required. lids with a compress and bandage, the parts being kept perfectly at rest. I need hardly say, that an ap- May mark parently simple cut in the eyelid may be only the a deeper injury. external indication of a wound which has penetrated deeply into the orbit; nor need I repeat the caution already given against a too hasty and favourable prognosis in such cases. loss of Incised wounds of the eyelids, by dividing the fibres May cause of the levator palpebræ, may destroy the action of the ptosis and muscle, and render it impossible for the patient to sight, raise the eyelid. In some few cases, injury to the lids or supra-orbital region, either from a contused or incised wound, has been followed by paralysis of the levator palpebræ. In other cases, not only has ptosis come on, but this has been attended by gradual loss of sight. In order to explain this connexion, we may presume that some of the branches of the fifth nerve from inhave been injured, that the irritation has extended jury to thence to the ophthalmic ganglion and carotid plexus, 5th nerve. Lacerated wounds, Require care. Burns. Mischief from cicatrices. Method of dressing. and ultimately involved the sympathetic in the morbid action; a permanently engorged state of the capillaries being thus induced, which interferes with the nutrition of the nervous elements, these become atrophied, and the result is the condition above noticed. However this may be, it is well to bear in mind the fact, that even apparently trivial injuries to the eyelids are sometimes followed by paralysis of the levator palpebræ, or by total loss of sight in the injured eye. Instances of this kind are not to be confounded with those depending upon detachment of the retina, consequent on a blow or fall on the eye; in these cases the loss of sight occurs immediately after the accident, and the ophthalmoscope will generally enable us at once to detect the nature of the injury. In the case of lacerated wounds of the eyelids, there may be a little more difficulty in adapting the torn edges of the wound to one another. Having previously been cleaned from foreign substances or clots of blood, they should be brought as accurately together as possible, and retained there by means of sutures, otherwise an ugly scar may result, or a cicatrix of considerable extent, which by subsequent contraction may evert the lid to a greater or less degree. Occasionally, from inattention to these apparently trivial matters, the edges of the wound do not unite, and a slit or button-hole opening through the lid remains.* BURNS.-The eyelids are sometimes damaged by fire, or the explosion of gunpowder, or other combustible material. Our chief care under these circumstances must be to prevent, if possible, the formation and contraction of a cicatrix, which is certain to occur unless the greatest care be taken in dressing the wound. A piece of lint soaked in oil or glycerine containing carbolic acid should be applied over the injured lid, together with a compress and bandage, so as to keep the lids well stretched over the globe of the eye until the wound has healed. The dressing may be changed two or three times a day, the wound being bathed with warm water from time to time; but over-anxiety to see it look clean is often attended with ill consequences. It will be well especially to avoid rubbing or daubing *Lawrence "On Diseases of the Eye," 2nd edit., p. 89. the surface of such a wound with a sponge or wet rag: simply changing the dressing night and morning, and reapplying the pad and bandage, will be quite sufficient. between the lids; vented. Should the edges of the lids be excoriated, they are Adhesions very apt to grow together, particularly at their inner and outer angles; the eye must then be opened more frequently, and the lids should be separated from one another as far as possible, so as to break down any adhesions that may have formed; the margins of the How preeyelids must be smeared with an ointment composed of equal parts of glycerine and starch boiled together, cacao butter, or any similar substance, not likely to excite irritation, but which will prevent the raw edges of the lids from coming in contact. In the majority of these cases it will be necessary also to employ a compress, as the free margins of the lids are hardly likely to be injured by mechanical or chemical agents, without the integument covering the eyelids also suffering. INFLAMMATION OF THE EYELIDS. THE LIDS. ERYSIPELAS.-The skin of the lids is liable to be at- ERYSIPEtacked by phlegmonous or erysipelatous inflammation, LAS OF the latter usually extending from the parts around, and not uncommonly following exposure to cold, or suppuration of the lachrymal sac. Vesicles. In these cases the lids become red, swollen, and Redness, tense; usually a number of small vesicles form on the Swelling, inflamed surface of the skin, and bursting, give exit to a sero-purulent fluid. The patient complains of a tingling, burning feeling in the part, but seldom of deep pain, unless the cellular tissue of the orbit is Pain. affected. In the majority of instances, the inflammatory action soon subsides and the parts return to their normal condition; but in severe cases the cellular May cause tissue sloughs and comes away in shreds, often da- sloughing. maging the muscular apparatus of the lid or destroying a considerable portion of the skin, and thus giving rise to ectropium. Treatment. In erysipelatous inflammation of the Treatment. lids, it is advisable to paint the skin over with a solution of nitrate of silver (3j to an ounce of water) in Nitrate of the early stages of the disease. This application should silver. |