EVISCERATION OF THE 
EYEBAEL. 
BY 
L. WEBSTER FOX, M.D., 
PHILADELPHIA. 
Abstract of a paper read before the American Medical Association, 
Ophthalmic Section, held in Baltimore, May 7, 1895. ' 
Reprinted from The Medical Bulletin. EVISCERATION OF THE 
EYEBALL* 
By L. WEBSTER FOX, M.D., 
PHILADELPHIA. 
THIS operation must not be confounded 
with abscission, although both are some- 
what similar in character. The latter oper- 
ation has been abandoned by the majority of 
ophthalmic surgeons on account of its risk. 
Evisceration consists in first excising the 
cornea and thoroughly removing the contents 
of the globe, and replacing the vitreous with a 
glass globe. Abscission of the cornea, as sug- 
gested by the older Critchett, was, probably, 
the best of a dangerous operation. In it no 
attempt was made toward emptying the con- 
tents of the globe. 
We are indebted to three English surgeons 
for bringing evisceration prominently before 
the notice of the profession practically. Mules's 
(of Manchester) first operation was performed 
in October, 1884. Brudenell Carter, who 
modified the abscission operation of Critchett 
some years ago, is now one of evisceration's 
most ardent advocates, while Bickerton, of 
Liverpool, performs it preferably to enuclea- 
tion. Frolich was the first surgeon to perform 
the evisceration. This he carried out in 1881, 
and named it "excochleation." Muldon and 
Graefe carried on their observations in 1884. 
* Abstract of a paper read before the American Medical Asso- 
ciation, Ophthalmic Section, held in Baltimore, May 7, 1895. Cubanton followed next with a series of ex- 
periments. I shall not review the literature on 
the subject, as it has been done by my friend, 
Dr. G. Oram Ring, in a very recent article* on 
the subject. My remarks shall be limited to 
my personal experience with some cases. 
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 eyelids, great pain, 
and an elevation of temperature (1050 in one 
patient, 105.50 in a second), that I felt dis- 
cretion was the better practice and removed 
both glass globes, later on removing the small 
stumps of the atrophied eyeballs. During the 
summer of 1893, while in Liverpool, Mr. Bick- 
erton 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 cour- 
age at his success. I also had the opportunity 
of witnessing the operations 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 follow the details of a written 
description, be it ever so clear and concise. 
The third patientf upon whom I performed 
this operation, June 29, 1894, at the Medico- 
Chirurgical Hospital, was a young Assinaboin 
Indian, from Montana, now at the Carlisle In- 
dian School. He was brought to the hospital 
by Dr. Montezuma to have the eyeball enucle- 
ated on account of pain and much discomfort. 
As near as we could get at the history of the 
* " Evisceration of the Eyeball," reported in the University 
Medical Magazine, April, 1895. 
f Reported in the Codex Medicos, Philadelphia, November, 
1894. 
4 loss of the eye, it was this : About three years 
previously, while on the plains, an inflamma- 
tion 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 removing the eyeball, 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 after twenty-four 
hours ; no untoward symptoms were present 
excepting the slight swelling of the upper 
eyelid. Toward evening the eyeball became 
somewhat painful, and the patient did not rest 
well during the night. Temperature, 102° F. 
The next day the temperature fell to 990 F. 
More swelling of the eyeballs appeared, with 
considerable chemosis of the conjunctive, but 
no discharge of pus. Chloral and a bromide 
were given to quiet the pain, and hot fermenta- 
tions were applied to the eyelids. On the 
third day the conjunctiva became very oedema- 
tousand protruded between the eyelids; other- 
wise the patient's condition was about the same 
as before. The internal treatment at this time 
was: Hydrarg. bichlor., gr. potass, bro- 
midi, gr. x; three times daily. To the pro- 
truding 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 
conjuctiva. The sclerotic swelling did not 
subside for ten days, when the pain disap- 
peared, and at no time during his residence at 
the hospital did it return. 
5 The operation was entirely successful, afford- 
ing 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 enucle- 
ation. 
Case 3. Operation performed October 26, 
1894, on a young woman,-a patient of Dr. 
Frutchey. She had been wearing an artificial 
eye over the blind eye for several years; the 
result was that she had symptoms of sympa- 
thetic irritation and pain in the partially-atro- 
phied eyeball. 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 factor in the 
causation of pain. The bone was growing 
larger and the sclerotic coat was restricting its 
growth; hence the pain. The bone was re- 
moved without difficulty and given to Profes- 
sor Laplace for microscopical examination. 
The patient had no untoward symptoms; the 
temperature ran up to 101° the first day after 
the operation, and on the third to i° above 
the normal line, but no visible change fol- 
lowed, the patient leaving the hospital in 
twelve days. In this patient there was no 
reaction, no swelling of the eyelids, and the 
conjunctiva but very slightly chemotic. The 
artificial eye stands out on a level with its 
neighbor. The movenlent is perfect, falling 
but little short of normal. 
Case 4. Young woman, aged 22 years, ad- 
mitted to the hospital on account of an irri- 
table left eye, staphyloma of the cornea,- 
6 eye useless. On account of the repulsive 
appearance of the eyeball the patient desired 
its removal so as to replace it with an artificial 
eye. 
The operation was performed under the 
same antiseptic precautions, with little or no 
reaction, no swelling of the eyelid and only a 
suspicion of oedema of the eyelid. Owing to 
a difficulty in matching the right in color the 
artificial eye is not quite large enough. The 
movement is exceedingly good. 
Case 5. Male, aged 33 years. In Sep- 
tember of 1884 he was struck in the left eye by 
a brass spring, puncturing the sclerotic, from 
which exuded a bead of vitreous. When 
brought to the hospital the vitreous was snipped 
off and the scleral wound was closed by stitch- 
ing over it the conjunctiva. The eye became 
involved in a general uveitis, with a result of 
total loss of vision and slight shrinkage of the 
eyeball. I saw this patient about once a year, 
and during the ten years no inflammatory 
change took place in the eyeball. The hyper- 
opia was fully corrected in the right eye 
and glasses worn. In January 13, 1892, the 
following note was made in my casebook: 
The sclerotic scar visible; through the con- 
junctiva no perception of light; total posterior 
synechia; lens cataractous; no perception of 
light. Tension, -1; eyeball manifestly shrun- 
ken; no pain or irritation. On December 26, 
1894, the patient came to see me on account 
of considerable congestion of the left eye 
and slight pain on pressure. The result of 
the examination revealed sympathetic irri- 
tation. The patient was placed on active 
mercurial treatment, which reduced the active 
symptoms,-both eyes became perfectly quiet. 
7 Having had this warning I advised the evis- 
ceration operation, which was performed Feb- 
ruary 2, 1895, at the Medico-Chirurgical Hos- 
pital. The operation was witnessed by Drs. 
Risley and Carpenter,-two members of the 
association. The case made a very good 
recovery, with little or no reaction; the only 
defect is a slight gaping of the conjunctiva 
and sclera, owing to the central stitches of 
both conjunctiva and sclera giving way and 
allowing the glass globe to be visible. The 
patient is, however, wearing an artificial eye, 
and no inconvenience has become manifest up 
to the present writing. 
Case 6. Child, female, aged 11 years. 
Staphyloma of the cornea of the left eye, due 
to an ulcer of the cornea, three years previ- 
ously; since then the cornea has developed into 
a very large staphyloma. The operation was 
performed May 3, 1895 ; at the present writing 
the patient is doing well. The details of the 
operation are carried out under ether. The 
eye is thoroughly irrigated with a lotion, which 
I call formula 1 to designate it from almost the 
same formula for sterilizing instruments. The 
eyelids are separated with the ophthalmostat. 
The conjunctiva is dissected from its corneo- 
scleral attachment back to about the equator of 
the eyeball, the muscle not being interfered 
with; then the cornea is excised,-this is best 
done with a large Beer knife, as if perform- 
ing a flap-operation for cataract,-the lower 
half of the cornea is removed with 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 body and choroid and the head of 
the optic nerve, leaving the clean, white 
8 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 haemorrhage. As 
this application 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 irrigated 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 split 
vertically so that the edges may be drawn 
together and held by stitches of fine catgut, 
completely hiding the glass ball, rIhe orbit 
is again thoroughly irrigated with the hot 
solution and the socket packed with sterilized 
cotton, over which is bound a sterilized band- 
age, and the patient is put to bed. 
Formula i. 
Irrigating Fluid. 
Hydrarg. bichlor., . . gr. 
Zinci sulphocarbolatis, . gr. xxx. 
Aq. menth. pip., . . 3xj. 
Aq. camph., 
Aq. destill., . . aa 
M. ft. sol. 
The same formula is used for instruments, 
without the hydrargyrum. 
In case 5, instead of using black silk to 
suture the sclerotic coat, sterilized catgut was 
used. Whether the knot became untied or 
whether absorption took place too rapidly, 
causing gaping of the wound and thus allow- 
ing the glass ball to press upon the conjunctival 
suture and cause it to tear, I am unable to say; 
but, from whatever cause, the glass ball is visible. 
9 The patient is now wearing an artificial eye 
without any inconvenience. 
When the operation is performed under strict 
antiseptic precautions very little or no reaction 
follows, and the result, as Mr. Mules states, 
"are not as disturbing to the normal relation 
of the parts outside of the sclera as in enuclea- 
tion." Dubanton and Graefe arrive at these 
conclusions: " That the procedure equaled in 
value enucleation in sympathetic disease, was 
safer as regards danger of purulent meningitis, 
can be performed in panophthalmitis, and 
that, whenever done, a better stump is always 
secured." 
If we have in evisceration a method equally 
as safe as in enucleation, we certainly have in 
addition the advantage of giving better support 
to an artificial eye, getting rid of the sinister 
stare, the enophthalmus, and more perimetric 
rotation, with no disagreeable muco purulent 
discharge so common after enucleation.