Evisceration of the Eye-ball. 
BY / 
R. WEBSTER FOX, M. D., 
Professor of Ophthalmology, Medico-Chirurgical College, 
PHILADELPHIA, PA. 
Reprinted from the Codex Medicus Philadelphia, November, 1894. 
PHILADELPHIA : 
Press of A. Van Horn, 119 North Sixth Street. 
1891 Evisceration of the Eye-hall. 
By L. Webster Fox, M.'D., 
Professor of Ophthalmology, Medico-Chirurgical College. 
THIS operation consists in first excising the cornea, then removing 
the contents of the eye-ball and replacing the vitreous with a glass 
globe. 
The cosmetic effect of an artificial eye is nearly always disappointing to 
the individual wherever he goes, and while the sinister stare may in a measure 
be minimized by glasses, yet the self consciousness of a defect to the individual 
always remains the same. Many patients, especially females, will wear a 
shell (artificial eye) over a stump, irrespective of the irritation thus produced 
and the very great risk of exciting such a grave disease as sympathetic 
ophthalmia. 
We are indebted to Mr. Mules for devising a means of preventing the 
burial of the artificial eye in the orbit. The operation was intended as a 
preventive of sympathetic ophthalmia, by removing the contents of the globe, 
leaving only the sclerotic coat behind, and also to make a better support for 
the artificial eye. Mules performed his first operation in October, 1884, since 
when he has operated many times. 
Frohlich, in 1881, was the first surgeon to perform evisceration. He 
named the operation “ excochleation,” but seemingly did not carry his re- 
searches very far. Mulder carried out the experiments on rabbits and the 
cadaver in 1884, while Graefe, in 1884, performed the same operation for the 
prevention of purulent meningitis. Mules’ operation differs from the others in 
the introduction of a hollow glass globe into the cavity of the denuded sclera ; 
his original operation has been somewhat modified by Drs. Brudnell Carter 
and T. Herbert Bickerton. 
In 1885, I performed the operation twice in the Germantown Hospital, 
but the reaction was so great, including tremendous swelling of the orbital 
tissue and eye-lids, great pain and an elevation of temperature, (105 in one 
patient, 105.5 in a second,) I felt that discretion was the better practice and 
removed both glass globes, later on removing the small stumps of the 
atrophied eye-balls. During the summer of 1893, while in Liverpool, Mr. 
Bickerton brought to my notice three patients upon whom he had recently 
operated. The cosmetic effect was so beautiful that I again became deeply 
interested and gathered renewed courage at his success. I also had the 
opportunity of witnessing the operation at the Liverpool Infirmary, by Mr. 
Bickerton, and also the after treatment. To see a skilled operator carrying 
out the technique of an operation is infinitely better than to try to follow the 
details of a written description, be it ever so clear and concise. 
The operation is performed under ether and is essentially as follows : The 
eye is thoroughly irrigated with a 1 to 1000 corrosive sublimate solution. The conjunctiva is dissected from its corneo-scleral attachment back to about 
the equator of the eye-ball, the muscles not being interfered with, then the 
cornea is excised. This is best done with a large Beer’s knife as in perform- 
ing a flap operation for cataract; the lower half of the cornea is removed with 
a curved scissors and the contents of the globe are taken out with a small 
scoop devised for the purpose. Great care is necessary to remove the ciliary 
bodies and choroid and the head of the optic nerve, leaving the clean, white 
sclera. Mr. Carter has devised a rubber bulb which is inserted into the 
scleral cavity and inflated with air, to produce pressure on the central artery 
to prevent hemorrhage. As this appliance has not been a success with me, I 
pack the scleral cavity with sterilized cotton ; after waiting a few minutes, this 
is removed and the contents of the scleral cavity are again thoroughly irri- 
gated with a hot antiseptic fluid. * 
A sterilized glass globe which is best suited to the case, is then inserted 
with a specially devised instrument, the sclera is slit vertically so that the 
edges may be drawn together and held by stitches of fine catgut, completely 
hiding the glass ball. The orbit is again thoroughly irrigated with the hot solu- 
tion and the socket packed with sterilized cotton, over which is bound a 
sterilized bandage and the patient is put to bed. 
The subject upon whom I performed this operation, June 29th, 1894, 
the Medico-Chirurgical Hospital, was a young Assinaboine Indian from Mon- 
tana, now at the Carlisle Indian School. He was brought to the Hospital by 
Dr. Montezuma, to have the eye-ball enucleated on account of pain and much 
discomfort. As near as we could get at the history of the loss of the eye, it 
was this : about three years ago, while on the plains, an inflammation of the 
left eye took place which gradually progressed to an ulceration of the cornea, 
and finally, to complete destruction of this part of the eye. Instead of remov- 
ing the eye-ball, a Mules’ operation was performed, under ether. The details 
of the operation were carried out without complication and the patient put 
to bed. 
The orbit was examined at the end of twenty-four hours. No untoward 
symptoms were present excepting a slight swelling of the upper eye-lid. 
Towards evening the eye-ball became somewhat painful and the patient did 
not rest well during the night. Temperature 102°. The next day the 
temperature fell to 990. More swelling of the eye-lids appeared with consid- 
erable chemosis of the conjunctiva but no discharge of pus. Chloral and a 
*The following is the formula for the lotion I use in all operations of the eyes : 
1* 
Hydrarg. Bichlor gr. 1-50 
Zinci Sulpho-carbolatis .... grs. xxx. 
Aq. Menth. Pip 5 u. 
Aq. Camph. 
Aq. Destil. aa § ii. 
M. Sol. ft. bromide were given to quiet the pain and hot fomentations were applied to 
the eye-lids. On the third day the conjunctiva became very cedematous and 
protruded between the eye-lids, otherwise the patient’s condition was about 
the same as before. The internal treatment at this time was Hydrarg. 
Bichlor., gr. 1-32, Potass. Bromidi, Potass. Iodidi, aa gr. x., three times 
daily. To the protruding conjunctiva pressure bandages were applied, 
which restricted the protrusion. 
The temperature fluctuated about the 990 line until July 7th, when it fell 
to normal and the various inflammatory conditions subsided. At the end of the 
week I removed the stitches from the conjunctiva. The sclerotic swelling 
did not subside for ten days when the pain disappeared, and at no time during 
his residence at the Hospital did it return. 
The operation was entirely successful, affording a beautiful support for 
the artificial eye which was adjusted July 18th. The artificial eye stood out 
full and prominent with almost perfect movement, a decided improvement 
over the results of the old operation of enucleation. 
On October 1 ith, the boy met with a peculiar accident which brought him 
back to the Hospital. While fastening a cow in the stable, the animal tossed 
her head and the horn struck the boy on the nasal side of the orbit ; the 
artificial eye was not broken, but was pushed well into the orbit, causing 
much tenderness but no swelling, the following day. The patient was kept 
in the Hospital for a week, and was sent home, wearing the artificial eye with- 
out discomfort. 
I fail to see how it is possible, in any way, to break the glass ball, 
embedded, as it is, in fat and guarded with a casing of sclerotic tissue. From 
a cosmetic standpoint, this operation is perfection. The comfort and freedom 
from secretion are certainly greater than with the old method. 
Case 2.—On October 26th, I performed the above operation on a young 
woman, a patient of Dr. Foster Frutchey. She had been wearing an artifi- 
cial eye over the blind eye ; the result was that she had symtoms of sympa- 
thetic irritation, and pain in the partially atrophied eye-ball. The operation 
was carried out in detail, as above described. Upon removing the cicatricial 
cornea, I found the scleral cavity filled with a bony mass, round, and shaped 
exactly like a small acorn. This growth of bone was also a very important fac- 
tor in the causation of pain. The bone was growing larger and the sclerotic coat 
was restricting it, hence the pain. The bone was removed without difficulty 
and given to Professor Laplace for microscopic examination. The patient had 
no untoward symptoms. The temperature ran up to ioi° the first day after 
the operation, and on the third, since when it has remained about normal. 
Whether I unconsciously made some improvement in my technique or whether 
my asepsis was more thorough, I am unable to say, but nevertheless there 
was no swelling of the eye-lids nor orbital tissue, and from present appearances 
the patient will return home at the end of a two weeks’ stay in the hospital. 
1304 Walnut St., Philadelphia. DR. FOX’S CASE OF EVISCERATION OF THE EYE-BALL.