Sympathetic Ophthalmia. 
REPORT OF FIVE CASES. 
By DR. S. C. AYRES, Cincinnati, Ohio. 
KPSPPINTED FROM THE 1RCHLFES ON OPHTHALMOLOGY AND 
Otology, Vol. V., No. 2, 18^€. FIVE CASES OF SYMPATHETIC OPHTHALMIA. 
Reported by Dr. S. C. AYRES, of Cincinnati, O. 
The question of the cause, development, and relief, or pre- 
vention of sympathetic ophthalmia, is one of deep interest to 
every specialist. This disease is often so slow and insidious, that 
it has developed its full force before the patient becomes alarmed 
and applies for advice. At other times it develops with wonder- 
ful rapidity, and goes on to total destruction of the eye, appar- 
ently regardless of all attempts to check it. It is, without doubt, 
one of the most intractable and destructive diseases we have to 
deal with, and can profitably be studied in all its different phases. 
It is the sword of Damocles hanging over the head of nearly 
every patient who has been so unfortunate as to lose one eye, 
threatening destruction of its fellow. How to avert its deadly 
fall is the question of vital importance. 
We are particularly warned against the dangers of sympathetic 
inflammation in cases where a foreign body has penetrated one 
eye, but it is a question whether such cases are in fact more likely 
to be followed by this fatal disease than other wounds. My ob- 
servations lead me to conclude that punctured and incised wounds, 
involving the cornea, iris, and ciliary body, are, in general, more 
productive of sympathetic trouble than foreign bodies remain- 
ing within the eye. 
In thirty-five enucleations made by Dr. Williams and my- 
self, for foreign bodies within the eye, only one case of sympa- 
thetic inflammation occurred. In these cases the foreign bodies 
had remained in the eye during different periods, varying from 
one day to twenty-three years. In all of them sympathetic irri- 
tation, photophobia, lachrymation, spasm of accommodation, and 
diminished acuity of vision were present to a greater or less ex- 
tent, but in none (with the exception of one case) was there plas- 2 
S. C. Ayres: 
tic iritis or irido-cyclitis. All of the thirty-four cases recovered 
with good vision in the uninjured eye, and there has been no sub- 
sequent trouble so far as heard from. 
I have excluded from this report many cases of probable sym- 
pathetic inflammation which were not seen until after the in- 
flammatory process had exhausted itself and both eyes were 
blind. 
In some of these the history was too unsatisfactory to be re- 
corded, while at the same time the probabilities were in favor of 
the loss of the uninjured eye by sympathy. 
The cases reported below were seen during the acute stages of 
inflammation, and the histories are clear in regard to the injuries. 
Case i.-Injury of the right eye by the beak of a bird. Sympa- 
thetic inflammation of the left eye in nine months, and loss of 
vision. 
W. M. M., aet. 9, a bright, healthy boy, met with the unfortunate ac- 
cident which caused the loss of his eyes in the following remarkable man- 
ner, as related by his father. He was standing near a cage in which a 
wild bird of the crane species, recently captured, was confined, and while 
the boy was looking through the bars the bird struck him with his beak. 
The wound inflicted was in the upper and outer quadrant of the cornea, 
crescentic in shape, and about 2'" in length. He suffered but little pain 
after the injury, although there was probably a prolapse of the iris and 
traumatic cataract. He retained perception of light for about four 
months, when it failed entirely. 
His father first noticed, in July, 1875, four months after the injury, that 
the sight of his sound (left) eye was not quite as good as usual, but the 
symptoms were not severe enough to excite his fear of any threatened 
trouble, and it was not until December, eight months after the injury, 
that he became fully convinced that his left eye was sympathetically af- 
fected. 
At this time the injured eye became red and irritable, and, at the same 
time, the left eye began to fail very perceptibly, and he was soon unable 
to read. Since then it has gradually failed, and he is now only able to 
count fingers at 4' and read Sn. 20 at 2". 
Status prcesens.-Right eye : Eyeball diminished in size, T-2, cornea 
flattened, sclerotic injected, corneal diameter diminished, complete an- 
terior synechiae, anterior chamber obliterated, eye tender to pressure. Left Sympathetic Ophthalmia. 
3 
eye : Normal in size, T-i, pinkish zone around cornea, complete 
posterior synechiae, iris dirty, rusty color. There is a dense, false mem- 
brane in the pupil. 
Enucleation of injured (right) eye advised, and performed March 22, 
1876. 
March 2^d.-Says that he sees objects much more distinctly than he 
could yesterday. Counts fingers promptly at 7'. 
The enucleated eye was examined by making a meridional section 
through the sclerotic. The vitreous was entirely disorganized. The ball 
was filled with a fluid of a dark amber color, in which were floating nu- 
merous roundish, blood coagula. The retina was stretched like a cord 
from the optic papilla forward to a roundish mass which had developed 
behind the cornea. The growth was as large as a small hazel nut, and 
its surfaces were convoluted with here and there minute ecchymoses on 
the surface. It seemed to have developed from the iris and ciliary 
body. The lens was entirely absorbed ; only a portion of its thickened 
capsule remained. The ciliary processes on the injured side of the 
cornea were atrophied and seemed to have become a part of the neoplasm. 
April ^th.-1Case progressing favorably. He now walks around without 
stumbling, and without assistance. Vision is about and he spells 
Sn. No. 20 at 3^". He counts fingers in a moderately lighted room at 8'. 
Pupil slightly dilated. 
May loth.-His father reports that his vision is not as good as it was 
last month. He sees with difficulty to go around, and it is quite evident 
that degeneration of the eye is going on. 
Case 2.-Injury of right eye by fragment of iron ore, sympa- 
thetic inflammation in nine weeks, and loss of vision. 
W. R. R., set. 46, laborer in an iron furnace, gave the following 
history of his case : In the latter part of October, 1875, he was breaking a 
piece of iron ore with a sledge hammer, when a small fragment flew off 
and struck the right eye. He had pains in the eye for a while, but soon 
recovered, and since then has suffered but little from it. There has 
always been a tender place on the upper portion of the globe, over the 
ciliary body, and the patient winces when it is touched. 
Vision was immediately destroyed by the injury. 
Status prcesens.-Eye shrunken and T-1. 
The inner and lower quadrant of the cornea is flattened, and presents a 
white, cicatrized appearance. The remainder of the cornea is transparent 
and the iris is seen through it, and lying in contact with it. 4 
S. C. Ayres: 
The pupil is filled with the opaque capsule of the lens. 
The conjunctiva immediately around the cornea and the subconjunc- 
tival tissue are injected, and the sclerotic has a dirty, yellowish ap- 
pearance. 
He could see with the left eye until about the ist of January, 1876. 
He then noticed that his sight was gradually failing, that objects in the 
distance were becoming indistinct; but still he suffered no pain. He 
has had constantly an appearance of "drops of water" before this eye. 
He continued work until the latter part of January, when he had to 
stop. Since then his sight has rapidly failed, and for the last few days he 
has had to be led around. He sees only shadows of the hand in front of 
the eye. The pupil is closed and contracted, and filled with a dense, 
false membrane. There is considerable ciliary injection, but the globe 
is not tender to pressure. T -f-1. 
An instillation of atropine was made, after which he was able to count 
fingers at 6". 
Left eye enucleated March 1^. 
He was ordered the Bichlo. Hydrar., gr. twice a day, and | 3. ung. 
Hydrar. to be rubbed into the skin at bedtime. 
March Mh.-Counts fingers at 4' and sees a ring on my finger. The 
patient is poor and had to return home. The Bichlo. Hydrar. to be 
continued at home. 
May 16th.-Patient has lost ground since he went home. A friend writes 
that he does not see as well as when he left the hospital. Can still see 
shadows, but it is evident that vision is gradually failing, and the eye will 
probably undergo atrophy. 
Case 3.-Injury of right eye by fragment of coal, sympathetic 
inflammation in the other in five weeks, total loss of sight. 
C. B., set. 5, received an injury of the right eye, August 29, 1875, by a 
piece of coal thrown at her. It inflicted a triangular wound in the cor- 
nea, and ruptured the capsule of the lens. There was prolapse of the 
iris, which was drawn out and snipped off. Suppurative irido-choroiditis 
rapidly supervened. The patient was a delicate, strumous child, and her 
confinement to the house and her sufferings told decidedly on her 
strength ; still, with the aid of tonics and good diet she was kept up. 
Her left eye remained entirely free from all symptoms of sympathetic 
inflammation until the latter part of September. The mother had been 
instructed to bring the child every two or three days, but at this time had 
failed to do so for more than a week. When seen, October 6, after this Sympathetic Ophthalmia. 
5 
long absence, the anterior chamber of the left eye was more than half full 
of lymph and pus, and the iris could scarcely be seen at all owing to the 
turbidity of the aqueous. Vision was reduced to bare perception of light. 
Enucleation of the right (injured) eye was now advised, and consented 
to by the parents of the little girl. 
In four or five days after the operation the left eye began to clear up, 
and steadily improved until the pupil and iris could be seen, and the 
child was able to go about the room alone and pick her playthings up. 
This encouraging state of affairs lasted only a few days, when the eye 
grew rapidly worse, and in a short time vision was entirely gone. The 
ball became partly atrophied (April, 1876), and the cornea flattened and 
opaque. The pain and photophobia disappeared, and the child's eye 
became comfortable, but vision was nil. 
In this case, although the enucleation was made within a few 
days after the symptoms of sympathetic inflammation began to 
manifest themselves, yet it had no effect in arresting the disease. 
If the mother had obeyed instructions, and brought the child in 
every two or three days, it might have made a difference in the 
treatment, but this is at least doubtful. 
Case 4.-Injury of left eye by the blade of a pocket-knife. 
Sympathetic trouble in six weeks and loss of vision. 
T. H., aet. 5, a beautiful, healthy boy, met with the unfortunate 
accident which caused his blindness, in the following manner : He was 
leaning over his brother's shoulder, who was at the time cutting a string 
with his penknife. As soon as the string was severed, the knife, carried 
upward by the impulse, penetrated the left eye at the outer margin of the 
sclerotic and directly over the ciliary body, but did not wound the lens. 
The cicatrix was situated in the horizontal mpridian of the eye, commenc- 
ing at the sclero-corneal margin and extending outward about 2'" in 
length. The eye is normal in size-pupil blocked up by dense, false 
membrane-anterior chamber very shallow. 
The pupil is oval, showing that the anterior chamber must have been 
opened by the wound. Vision is entirely lost. 
About six weeks after this injury was received the right eye began to' 
fail. He never complained of it or suffered pain in it, but his parents; 
noticed that he could not see well. The impairment of vision gradually 
increased, and at the present time he is barely able to see letters of 20 Sn. 
at 4,z. There is complete posterior synechiae, the pupil is contracted and 6 
5. C. Ayres: 
blocked up by false membrane, anterior chamber very shallow, but the T 
was not diminished. While the iris was discolored, yet it was not vascu- 
lar, and it was supposed that an attempt at iridectomy would be followed 
by favorable results. 
The injured eye was first enucleated, in the hopes that it would remove 
the source of irritation and give the other eye a better chance. 
Sectio Oculi.-A meridional section of the eye was made, and the vitreous 
was found partly liquefied and of a pale straw color ; the anterior portion, 
however, retained its normal consistency. Lying directly below the 
cicatrix was found a clot of blood about the size of a bird shot. The lens 
was transparent and in situ, showing that the knife had passed directly 
backward without wounding it. 
July 30, 1873. Iridectomy made in left eye. The iris was so firmly 
adherent to the capsule of the lens that it was impossible to remove much, 
but a small piece was excised. Hemorrhage from the iris interfered with 
the operation, and the anterior chamber was soon so full of blood that 
the iris could not be seen. 
July 31. No pain in eye ; wound healed; anterior chamber still filled 
with blood. 
August 4. Blood nearly all absorbed ; coloboma visible ; lens cov- 
ered with pigment from iris; counts fingers at 4". 
Patient now went home with instructions to his father to keep him 
quiet, and not expose the eye to bright light, and to use atropine. 
Returned September 29th, in excellent physical condition. His eye, 
however, has not improved, and it is quite evident that degeneration of 
the globe is going on. Tension 1, eyeball flattened at point of incision 
for iridectomy, iris vascular and in contact with cornea, pinkish zone of 
injection around cornea, vision reduced to perception of shadows of hand. 
Was seen afterward in November, when the eye presented very much the 
same appearance as at the previous examination-V = perception of 
shadows. 
Case 5.-Rupture of sclerotic of the right eye and recovery 
of good vision. Sympathetic inflammation in left eye and loss 
of vision. 
E. W. M., set. 38, has in some respects a very remarkable case. He 
gave the following history : On the night of January 2, 1875, he had 
occasion to go out to the pump for water. The handle happened to be 
up, and as the night was dark, he ran against it. It struck the outer Sympathetic Ophthalmia. 
7 
side of the ball, and stunned him severely. Vision was immediately so 
impaired that he could only distinguish light from darkness. 
He treated the injury with cold applications, and in a short time was 
relieved, of pain. 
In about six weeks his left eye began to fail. It commenced gradually 
with a foggy appearance before it, which grew thicker, and in about one 
month he was only able to distinguish the motions of his hand. The 
progress of this inflammation was attended with pain in both eyes, but 
particularly in his left. 
He is a delicate-looking man, and as it is now (April 6, 1875), three 
months since the injury was received, he presents an ansemic appear- 
ance, owing to his close confinement and suffering. 
Stattis prcesens.-The right eye has suffered a rupture of the sclerotic 
inwards, opposite the point where the pump-handle struck the eyeball. It ex- 
tends fully one-third around the globe, and is situated in the usual place 
between the margin of the cornea and the insertion of the rectus muscle. 
The conjunctiva on the inner half of the globe presents a bluish-black 
appearance from the amount of blood extravasated under it. Under the 
conjunctiva, between the cornea and the caruncle, is a roundish elevation 
which is evidently the dislocated lens. The anterior chamber appeared 
very deep, and a small segment of the iris can only be seen downwards, 
the rest of it having disappeared entirely. 
The media are turbid, but a faint red reflex can be seen from the fun- 
dus. V-shadows of hand. Eye free from pain, and no photophobia. 
In the left eye, the pupil was filled with dense, false membrane, there 
was complete posterior synechia, the anterior chamber was very shallow, 
the iris appearing almost in contact with the cornea, and there was azone 
of injection around the anterior portion of the globe. Within the past 
week he has had but little pain in it. He-can barely see shadows of the 
hand. 
He was ordered to the hospital, where h'e was instructed to remain 
quietly in a darkened room, but was allowed to take gentle exercise in 
the hall when the light was not too strong. He was placed upon the use 
of Hydrarg. Bichlo. gr. and Tind. Cinch. Comp., 3j. bis die. Instilla- 
tions of Sulph. Atrop. were made three to four times daily. 
His injured eye began very soon to show signs of improvement. In 
three or four days he could count fingers at T, and in a week at 4'. He 
was first tested with Snellen's test type, April 19th, when, with+ 3^, his 
almost, and he was able to read Sn. No. 6 with + 2|. 
His left eye also improved some. The pupil dilated very slightly up- 8 
S. C. Ayres : 
ward, and he could count fingers at 8". The iris assumed a more 
healthy color, and the ciliary injection almost disappeared. 
He was now allowed to return home, but was required to keep up the 
treatment as above until his return. 
May 7. Injured eye (right) much improved in appearance. Blood 
under conjunctiva has almost disappeared, tension of globe normal and 
vitreous clear. and reads Sn. 2^-. 
His left eye is hardly as good as when he left here-still it is not painful 
and there is no indication for interference. 
Aug. 21, '75. During the last three months the right eye has remained 
unchanged and vision is as good as when last tested. He has no pain 
in it and with his glasses he sees very satisfactorily. The left eye however 
has grown worse. There is intense ciliary injection. The tension is in- 
creased. Pupil closed with lymph, and iris bulging forward almost in 
contact with the cornea. 
An iridectomy was made by Dr. Williams in hopes that it would arrest 
the inflammation and that the eye would at last become quiet, even if no 
improvement in vision resulted. Owing to the fact that the iris was ad- 
herent to the capsule of the lens, there was great difficulty in drawing it 
out, but after several attempts a small portion was removed. 
The final result of the operation, April 30, '76, has been that the tension 
of the eye is now about normal, the ciliary injection has disappeared, and 
the eye is free from pain, but vision is practically nil. 
In an analysis of these cases we note the following points of 
interest: 
In three of them, 1, 2, and 3, the wound was in the cornea 
and was complicated with prolapse of the iris and traumatic 
cataract. 
In one, case 4, it was situated at the sclero-corneal junction, 
opening the anterior chamber and causing prolapse of the iris 
but not wounding the lens, and in case 5 there was rupture of 
the sclerotic with dislocation of the lens under the conjunctiva. 
I he periods at which sympathetic inflammation developed 
were as follows : In case 3 at five weeks, in cases 4 and 5 at 
six weeks, in case 2 at nine weeks, and in case 1 slight symp- 
toms at four months, but none severe until nine months after 
injury. 
In case 3 enucleation of the injured eye was made within a Sympathetic Ophthalmia. 
9 
few days after development of sympathetic trouble, but it had 
no more influence in arresting the fatal disease than it did in 
cases I, 2 and 4, where it was made a few weeks later. The 
operation seems to have had no effect in retarding or modifying 
the progress of the disease in any of these cases. 
One striking feature in these cases is the freedom from pain 
in all, with the exception of No. 5, and this may be partly 
accounted for by the fact that he was a man of nervous tem- 
perament, and fully alive to his dangerous condition. 
As after-treatment is generally unavailing, we are forced to 
look to a preventive treatment to escape the results of this 
apparently intractable disease. This must consist in an iridec- 
tomy, if made soon after the injury, taking particular care to 
free the wound of imprisoned iris, and at the same time to remove 
as much of the lens as possible, when it has been injured. In 
connection with this we must enforce rest of the eye as well as 
the body. Use cold externally, atropine, anodynes and in some 
cases tonics or alteratives as may be indicated. 
If plastic iritis or irido-cyclitis has set in, all operative inter- 
ference, excepting enucleation, maybe contra-indicated, and this 
latter, if the eye is severely injured and likely to become blind, 
or if any evidences of sympathetic trouble manifest themselves, 
must be insisted on.