EVISCERATION OF THE 
EYEBALL 
/Viule’s Operation—Insertion of Artificial Vitreous 
(Glass V>a\\). 
By L. WEBSTER FOX, YU)., 
Professor of Ophthalmology in the Medico-Chirurgical College, Philadelphia. 
THIRD PAPER. 
Reprinted from The Medical Bulletin. EVISCERATION OF THE EYEBALL. 
Mule’s Operation—Insertion of Artificial 
Vitreous (Glass Ball). 
BY- 
L. WEBSTER FOX, 1VL.JJ., 
Professor of Ophthalmology in the Medico-Chirurgical College, Philadelphia. 
Third paper. EVISCERATION OF THE EYEBALL.* 
Mule’s Operation-Insertion of Artificial Vitreous (Glass Ball). 
Professor of Ophthalmology in the Medico-Chirurgical College, Philadelphia. 
L. WEBSTER FOX, M.D., 
At the last meeting of the American Med- 
ical Association, Section of Ophthalmology, 
May 7jio, 1895, I called the attention of the 
profession to this operation. Since then I 
have added a number of operations to my 
list, and I shall in this contribution give a 
brief resume of the present condition of 
those cases previously described, and also 
enter more fully into detail upon the recent 
operations, as well as give my experience 
upon the outcome of certain modifications 
in the surgical technique. 
Case 3. Operation performed Oct. 26, 
1894, on a young woman, a patient of Dr. 
Frutchey. She had been wearing an arti- 
ficial eye over a blind eye for several 
years. The result was that she had sympa- 
thetic irritation and pain in the partially 
atrophied eye-ball. The operation was car- 
ried out as described in the above-men- 
tioned paper. Upon removing the cicatri- 
cial cornea, I found the scleral cavity filled 
with a bony mass, round, and shaped exact- 
ly like a small acorn. This growth of bone 
was also a very important factor in the caus- 
ation 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 Pro- 
fessor Laplace for microscopic examination. 
The patient had no untoward symptoms; 
the temperature ran up to 101 the first day 
after the operation, and on the third to one 
degree above the normal line, but no visible 
change followed—the patient leaving the 
hospital in twelve days. In this case there 
was no reaction, no swelling of the eyelids, 
and the conjuctiva but very slightly che- 
‘motic. The artificial eye stands out on a 
level with its neighbor. The movement is 
perfect, falling but little short of normal. 
At the end of one year there are no un- 
toward symptoms whatever, and the artifi- 
cial eye, from a cosmetic point, is a perfect 
success. 
Case 4. A young woman of Philadelphia, 
aged twenty-two, admitted to the hospital 
on account of an irritable left eye, staphy- 
loma of the cornea; eye useless. Owing to 
the repulsive appearance of the eye-ball, the 
patient desired its removal, so as to replace 
it with an artificial eye. The operation was 
performed January 25, 1895, under the 
same antiseptic precautions, as in all of 
these operations with little or no reaction, 
no swelling of the eyelids and only a suspic- 
ion of edema of the eyelids. Owing to a 
difficulty in matching the right eye in 
color, the artificial eye is not quite large 
enough. The movement is exceedingly 
good, and the patient has been working in a 
mill ever since the adjustment of the eye 
without any inconvenience whatever. 
Case 5. Male, age thirty-three, from Wil- 
mington, Delaware. In September, 1884, 
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 stitching 
the conjunctiva over it. The eye became 
involved in a general uveitis, with a result 
of a total loss of vision and slight shrinking 
of the eyeball. I examined this patient 
about once a year, and during the ten years 
past no inflammatory change has taken 
* Third paper. 4 
EVISCERATION OF THE EYEBALL. 
place in the eyeball. The hyperopia was 
fully corrected in the right eye and glasses 
worn. On January 13, 1892, the following 
note was made in my case book: “The 
sclerotic scar visible through the conjunc- 
tiva; no perception of light; total posterior 
synechiae; lens, opaque. Tension 1, eye- 
ball manifestly shrunken; no pain or irrita- 
tion. 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 irritation. The patient 
was placed on active mercurial treatment, 
up in ten days so completely that'nothing 
remained of this space. The artificial eye 
was replaced at the end of four days after 
the globe came out, and no untoward 
symptoms developed. It was interesting to 
watch the posterior part of the scleral cavity 
during the time that the glass globe was in 
place. The sclerotic coat remained perfectly 
white and clean—no new formed blood-ves- 
sels, nor any deposit of neoplasm was made 
between the globe and sclerotic coat. There 
evidently was a contraction of the tissues 
posterior to the equator of the glass globe, 
and this contraction caused the expulsion of 
the glass ball. The photograph, No. 5, was 
taken before the expulsion of the glass ball. 
The artificial eye was perfect in all its peri- 
metric movements and there was no enoph- 
thalmus. The remains of the sclerotic coat 
was not removed, and now makes a fairly 
satisfactory substitute for the glass ball. 
The movement of the eye is restricted and 
encphthalmus marked. The case is now 
one of evisceration simple. 
Case 6. Child, female, age 11 years, from 
Milford Mills, Chester Co., Pa. Staphy- 
loma of the cornea of the left eye, due to an 
ulcer of the cornea, three years previously; 
since then the cornea has developed into a 
very large staphyloma. The operation was 
performed May 3, 1895. For ten days the 
case progressed most favorably, no swell- 
ing of eyelids, nor pain. It was then discov- 
ered that the stitches in the conjunctiva 
were giving way, and the glass ball was 
making its appearance, proving that the 
stitches in the sclerotic had evidently been 
absorbed; in a week the glass ball came 
out and the cavity closed, and made a very 
satisfactory cavity for an artificial eye,which 
the child is wearing without inconvenience. 
There is some enophthalmus, but not nearly 
so great had the whole of the sclerotic coat 
been removed. This was the second case in 
which the catgut had been substituted for 
the silk suture, and the result might be 
called a failure. 
Case 7. A young woman, age 20, of Phil- 
adelphia. This patient was admitted to the 
wards of the hospital June 7, 1894, for in- 
tense hyperesthesia of the retina. The pa- 
tient suffered intense agony, the hyperes- 
S- ig. I 
which reduced the active symptoms; both 
eyes became perfectly quiet. Having had 
this warning, I advised the evisceration 
operation, which was performed February 
2, 1895, at the Medico-Chirurgical Hospital. 
The operation was witnessed by Drs. Risley 
and Carpenter. 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 become visible. 
A little less than one-half of the glass ball re- 
mained exposed until August 25, 1895,when 
it came out, leaving a cavity, which closed EVISCERATION OF THE EYEBALL. 
5 
thesia extending over the face, down the 
neck and between the scapula to the dorsal 
region. The combined professional skill of 
Professors Anders and Burr availed but 
little, all remedies proved useless—the in- 
tense pain could only be controlled by 
hypnotics. Suddenly a cessation in the 
general symptoms became manifest, and a 
severe iritis developed in the right eye. The 
line of treatment was directed towards the 
inflammation of the iris. In spite of all 
treatment the pupil closed, and vision, even 
to light perception, disappeared. The left 
eye during all this time never showed any 
sympathetic irritation, only an outbreak of 
retinitis. Having tried every remedy at 
my command, even to cauterizing over the 
fifth cervical ganglion, which was suggested 
by my friend, Dr. Shakespeare, and all to 
no avail, and, noticing a gradual shrinking 
of the eyeball, I performed an iridectomy, 
March 18, 1895. This operation brought 
temporary relief, and there is no doubt that 
some cessation was gained in the intense 
pain in both eyes. The patient gradually im- 
proved until July 1, 1895, when the eye 
symptoms and slight pressure upon the 
fifth cervical ganglion became as painful as 
ever. These symptoms, as well as pain in 
the now blind and shrunken eye, gradually 
became so intense that I determined to re- 
move the blind eye. On July 15, '1895, 
Mule’s operation was performed, and, 
strange to relate, almost every symp- 
tom of pain disappeared within the week. 
The orbit took on little or no swelling, and 
the patient is wearing an artificial eye in 
comfort. I have merely given a brief out- 
line of this case—her suffering at times was 
beyond belief, and it would have been a 
blessing had death relieved her when the 
paroxysms of pain were at their height. She 
was fed for three months by rectal enemata, 
the stomach being unable to retain any food 
at all; even the accumulation of mucus 
would cause intense retching. Whether it 
was a coincident that the disease had reached 
its culmination at the time of the Mule’s 
operation, or whether the removal of inflam- 
matory focus in the right eye brought about 
this change for the better, I am unable to 
say, but the patient has made a perfect re- 
covery, and while still muscularly weak, is 
able to perform light household work. Silk 
sutures were used in stitching the sclerotic 
and conjunctiva, and the parts remained in- 
tact . 
Case 8. Solomon Moore, negro, of Ger- 
mantown, presents some interesting fea- 
tures. Several years ago he had a cataract 
removed from each eye by capable sur- 
geons, yet both pupils closed and blindness 
followed. Upon examination with the oph- 
thalmoscope, I found that he had good per- 
ception of light in one eye, the other was 
blind. This information was elicited by 
standing the patient with his back to the 
gas jet, then with the mirror throwing the 
Fig. 2. 
light into his eyes from various directions, 
he was able to tell me from which quarter 
the light came, and I was convinced that if 
an artificial pupil was made vision might 
be restored to them. I performed an iri- 
dotomy with most excellent results,—with 
proper glasses the patient is able to follow 
the ordinary work of a day laborer.* 
On June 13, 1895, the man returned to 
the hospital with an angry looking eye, and 
as the eye was totally blind I advised its re- 
moval. The day following I performed the 
Mule’s operation. He was kept under ob- 
servation for two weeks, during that time 
Case reported in detail elsewhere. 6 
EVISCERATION OF THE EYEBALL. 
there was little or no reaction, and at the 
end of four weeks an artificial eye was ad- 
justed, which is perfect in its movement. 
When he was last at the hospital his seeing 
eye was free from irritation. 
Case 9. A young man of Philadelphia, 
age 21, patient of Dr. Ballantine. Ciliary 
region of the left eye was punctured with 
the sharp point of a peach stone, upper and 
out quadrant, thrown by a companion from 
the second story of an amusement hall. He 
was taken to a hospital, where for one week 
the eye was treated. One week after the ac- 
cident, August 7, 1895, the case came under 
my care; at this time the eyeball was con- 
gested, pupils dilated (mydriatic), yellowish 
reflex from fundus, showing inflammatory 
especially prepared for this septic case; I 
could not but feel that silk sutures in a case 
like this might harbor germs, and at some 
time break out into an inflammatory condi- 
tion. 
The patient remained in the hospital 
twelve days; very little or no reaction took 
place, only slight edema of the conjunctiva 
and orbital tissue. The upper eyelid was 
somewhat puffed and swollen from the first 
to the fourth day, after this the swollen con- 
dition disappeared. 
The patient went to Atlantic City. On the 
second or third day at this place, while 
walking along the boardwalk, he suddenly 
turned his head to the left and immediately 
felt something eive way in his eye. On Au- 
gust 23, the next day after the accident hap- 
pened, he came to see me. The glass ball 
was exposed. I tried to bring the parts 
together with catgut sutures again, and 
succeeded, but the parts would not hold, 
and on August 31 I removed the globe, 
cavity closed, and on September 10 an arti- 
ficial eye was inserted, which has been worn 
with comfort ever since. 
This was the third case in which catgut 
sutures were used and a third failure must 
be recorded. 
Case 10. Thomas Marsh, of Chester, Pa., 
age 47, was brought to the hospital by Dr. 
S. H. Neal, September 13, 1895. While at 
work in the morning between 7.30 and 8 
o’clock he was struck in the eye by a splin- 
ter of steel, cutting the eyeball open from 
the ciliary region on the nasal side to the 
temporal side, directly through the upper 
third of the cornea, causing a gaping 
wound. There was loss of lens and vitre- 
ous, and the eyeball had collapsed. The 
patient came to the hospital, and at 1 o’clock 
an evisceration of the eyeball was perform- 
ed. The case followed the usual course of 
recovery and was given an artificial eye to 
wear on October 25. The eyeball is perfect 
in its movements and the conjunctiva is 
firmly united. Black silk sutures were used 
in this case. 
Case 11. William Simpson, of Philadel- 
phia, age 52, referred by Dr. Saltmarsh. 
Far-sighted for many years, and for the last 
seven years obliged to wear glasses for dis- 
Fig. 3. 
cyclitis, eye-ball hard and very painful to 
the touch; no light perception. 
Three days after his admission to the 
hospital Mule’s operation was performed. 
After the abscission of the cornea I pro- 
ceeded next to remove the infiltrated vit- 
reous. The ciliary bodies were covered 
with pus—the same condition existed in the 
choroid. The vitreous and retina were not 
recognizable, both being nothing but a 
purulent mass. As this was the first case of 
the kind, I took unusual precaution to 
cleanse the scleral cavity perfectly. I pro- 
ceeded in the usual manner to carry out the 
technique of the operation, until I came to 
stitching the sclerotic—thinking that prob- 
ably the catgut, which I used on the two 
prior operations was not up to the standard, 
I used a different strand, which had been EVISCERATION OF THE EYEBALL. 
7 
tant vision—spherical plus. On April i, 
1895, he noticed an inflammation of the eye 
and consulted an ophthalmic surgeon, who 
discovered in connection with slight ciliary 
congestion a detachment of the retina, pos- 
sibly due to an injury (recalled having been 
struck in the eye with a clothes-line) and 
after three weeks’ treatment it was pro- 
nounced better with retina again attached. 
In a few weeks had another attack, even 
worse than the first, and found that the sight 
had gradually disappeared until the eye was 
totally blind, and very hard and painful. On 
October 2, 1895, the patient came under my 
care at the Medico-Chirurgical Hospital 
suffering greatly from an attack of glau- 
coma. Tension and eyeball very much con- 
gested. The cornea was hazy, pupil dilated 
and a faint white reflex from the fundus by 
oblique illumination. It could not be deter- 
mined positively whether we had a growth 
to deal with or a new formed tissue follow- 
ing complete detachment of the retina. The 
patient could not make up his mind to have 
the eyeball removed without a still further 
trial of internal treatment. The futil- 
ity of the treatment become more patent 
to the patient from day to day. On October 
19,1895, an evisceration was performed with 
the usual precautions. Upon removing the 
cornea and taking out the contents of the 
eye-ball I found a fibrous mass of tissue, 
which contained in its centre a spicula of 
bone, evidently starting from the cells of the 
choroid. Black silk sutures used in sclerotic 
and conjunctiva. The conjunctival stitches 
were removed on Monday, November 2. 
The patient has made an excellent recovery. 
Since the failure of three cases which I 
attribute to the too rapid absorption of the 
catgut sutures, thereby allowing the scler- 
otic coat to open and the conjunctiva, not 
being able to resist the evident pushing for- 
ward of the glass globe by the contraction 
of the sclerotic coat from behind, I have 
gone back to silk sutures. I have also 
given up using absorbent cotton to pack the 
sclerotic cavity, but use immediately after 
the evisceration sterilized gauze. After the 
packing, the blood which oozes from the 
central artery is taken up by the gauze, 
which expands and thus exercises enough 
pressure to stop all hemorrhages, leaving 
the scleral cavity perfectly dry. I deem 
this a great improvement over the original 
operation. 
The details of the operation are carried 
out under ether, as follows: The eye is 
thoroughly irrigated with a lotion, which I 
call formula No. i, to designate it from al- 
most the same formula for sterilizing instru- 
ments. 
FORMULA I. IRRIGATING FLUID. 
Hydrarg. bichlor 1-50 grain. 
Zinci sulphocarbolatis 30 grains. 
Aq. menth. pip 2 drachms. 
Aq.l camph 
Aq. destil., of each 2 ounces. 
M. ft. sol. 
The same formula is used for instruments 
without the hydrargyrum. 
The eyelids are separated with the oph- 
thalmostat. The conjunctiva is dissected 
from its corneo-scleral attachment back to 
about the equator of the eyeball, the muscles 
also separated; then the cornea is excised—- 
this is best done with a large Beer knife, 
as if performing 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. 
(Fig. i.) devised for the purpose. 
Great care is necessary to remove the cil- 
iary bodies and choroid and the head of the 
optic nerve, leaving a clean white sclera. 
Mr. Carter has devised a rubber bulb (Fig. 
2) which is inserted into the scleral cavity 
and inflated with air to produce pressure 
Fig. 4. 8 
EVISCERATION OF THE EYEBALL. 
on the central artery to prevent hemor- 
rhage. As this application has not been a 
success with me I pack the scleral cavity 
with sterilized gauze. After waiting a few 
minutes this is removed, and the contents 
of the scleral cavity are again thoroughly 
irrigated with antiseptic fluid and again 
packed. A sterilized glass globe (Fig. 3), 
which is best suited to the case, is then in- 
serted with a specially devised instrument 
(Fig. 4). The sclera is split vertically so 
that the edges may be drawn together and 
held by stitches of No. 4 black silk, using 
large needles, completely hiding the glass 
ball. The orbit is again thoroughly irriga- 
ted with the hot solution, and the socket 
packed with sterilized cotton, saturated 
with lotion No. 3, and this dressing is kept 
wet day and night for twenty-four hours, 
when the eye is bathed with hot water and 
fresh dressings again applied and continu- 
ously saturated with the lotion, over 
which is bound a sterilized bandage. 
FORMULA. 
Liq. plumbi subacetatis..... .2 drachms. 
Tinct. opii 
Tinct. belladon., of each. ...1 y2 drachms. 
Tinct. arnicae 1 ounce. 
Aq. camph 
Aq. destil., of each, q. s. ...ad 4 ounces. 
At the end of the twenty-four hours the 
upper eyelid is somewhat swollen, puffy 
and edematous, but the tumefaction grad- 
ually disappears. As a rule the conjuncti- 
val sutures are not removed under six or 
ten days. It is important that both eyes 
are kept bandaged for at least six days. By 
allowing the liberty of one, too much rota- 
tion of the eye is permitted, and as a se- 
quence the antagonistic muscles of the 
operated eye pull apart and there is greater 
pressure brought against the sutures, which 
are liable to be torn out—a probable cause 
in cases of No. 5, 6 and 9. 
From the large number of operations 
now under observation, and no unfavorable 
ones reported, it may be considered a very 
safe one, and if we have in evisceration a 
method equally as safe as in enucleation, 
why not give the patient the advantage of 
the much improved appearance of the arti- 
ficial eye? 
The patients were operated upon at the 
Medico-Chirurgical Hospital, and the best 
attention given them, as to the carrying 
out of the treatment by the house surgeons 
and nurses. The accompanying photo- 
graphs show the result of the operations as 
they appear at present writing. 
(Charles Lentz & Sons have succeeded 
in making the special instruments required 
for this operation). Case 3. 
Case 4. 
Case 5. 
Case 7. Case 8. 
Case 9. 
Case io. 
Case it.