Year : 1955 | Volume
: 3 | Issue : 1 | Page : 17--19
Subconjunctival rupture of the sclera and dislocation of the lens
B N Bhaduri
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Bhaduri B N. Subconjunctival rupture of the sclera and dislocation of the lens.Indian J Ophthalmol 1955;3:17-19
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Bhaduri B N. Subconjunctival rupture of the sclera and dislocation of the lens. Indian J Ophthalmol [serial online] 1955 [cited 2020 Jul 4 ];3:17-19
Available from: http://www.ijo.in/text.asp?1955/3/1/17/33570
Subconjunctival rupture of the sclera and dislocation of lens due to trauma is not of infrequent occurrence but the retention of useful vision in such instances is rare. Such ruptures are more common in aged people and are attributed to the loss of elasticity of the sclera in old age. The injury is usually due to a large blunt body being driven into the orbit between the globe and the orbital wall.
A case is reported here where useful vision was retained and the injury was caused by a fish known as Anabus testudeneus commonly known as climbing perch and in local vernacular "Koi" fish.
Jugal Kishore Bag, aged 5- years, a fisherman presented himself for examination for swelling in the upper part of the left eyeball, photophobia and dimness of vision following an accidental injury in the left eye. Duration 9 days.
History :- He was struck by a climbing perch fish on the left eye whilst he threw the catcher over the fishes in the shallow water of a tank standing in knee deep water. The catcher which is known as `pouli' is a cage-like bamboo structure of 2½ feet height, pyramidal in shape, open at both ends. The broad end is pushed over the fish and the cage is then fully submerged in water because the "Koi" thus dies when kept completely submerged in water. In the present case the fish jumped out through the upper opening and struck him on the left eye as he bent over the upper opening to inspect the contents of the catcher before pulling it out of the water with the fish. After the strike he fainted and fell in the water but was brought on dry ground where he regained consciousness. The offending fish was found to weigh about half a pound. After the accident, the patient complained of pain in keeping the eye open or blinking. The local physician prescribed Mercurochrome 1% instillations. This treatment was carried on for 4 or 5 days. The eye could, then be opened without any pain but could see things only indistinctly. An abscess of the upper part of the eye ball was diagnosed and he was advised to go to , Calcutta for treatment.
The condition of the eye at the time of examination
There was partial ptosis in the left eye. There was no swelling of the eyelids and no ciliary tenderness. On palpation, intraocular tension of the injured eye was found to be same as that of the other eve and not soft. With effort the patient could raise the left upper lid and no damage to the eyelid was observed. On raising the upper lid, a swelling was observed about 10 mm. above the upper part of the limbus [Figure 1]. The swelling was not tender or fluctuating. In the upper medial quadrant, a bluish linear scar was seen parallel to the limbus about I cm. away from the latter. The conjunctiva, on examination was found to be not ruptured and the scleral wound was found to be closed. There was some congestion of the bulbar conjunctiva over the scleral wound but no chemosis or subconjunctival hemorrhage was seen. The cornea was clear and without any damage. The pupil was large and drawn up and inwards, showing a large coloboma. The anterior chamber was deep in the lower portion and the lens was not seen. On ophthalmoscopic examination, apart from aphakia the vitreous was found to be clear, the optic disc normal and the retina was noted to be unaffected. There was no tear, hemorrhage or detachment in the retina. Macula appeared normal. The central vision improved to 6/15 with plus 10 Dsph.
The patient was admitted later on in R. G. Kar Medical College Hospital in my ward. The intraocular pressure was taken with Schiotz tonometer and found to be 22 mm. of Hg. (Schiotz.) in both the eyes. A diagnosis of subconjunctival dislocation of the lens through ruptured sclera was made and under local anesthesia the lens was removed through an incision in the conjunctiva parallel to the limbus at the upper border of the swelling. The lens was removed by a vectis and was found to be in capsule. After the removal of the lens the conjunctival incision was enlarged and the scleral surface closely examined but no other wound was noticed in the area. The coniunctival wound was closed with continuous suture. The patient made an uneventful recovery.
The vision improved to 6/9 with plus 11.00 Dsph. after two months from the date of discharge from the hospital.
From the history and examination of the patient, it is evident that the rupture of the sclera in the present instance is an example of a complete indirect rupture. Had it been a direct one then the position of the rupture would have been either below the lower pole of the cornea or including the lower pole of the cornea as the patient was looking down over the apical opening of the catcher. From the nature of the injury, it seems the head of the fish which is hard and blunt may have been driven into the orbit between the eyeball and the orbital wall, as the fish jumped out of the catcher whilst the fisherman was looking down. The direction of the force in the present case was upwards and inwards, as the blow was received in the lower and outer parts of the orbit where the bony protection is not present. The site of the rupture in this case is situated in the upper and medial quadrant of the globe, the commonest site of rupture in the indirect variety. The opening of the rupture was sufficiently large to allow the lens in capsule to come out of the wound, but the union later on, simply by keeping the eyelids closed indicate the good apposition of the margin of the rupture and absence of tissue in the wound. It is remarkable that although the injury was forceful to cause the rupture of the globe, there was no swelling of the eyelids, and even if there had been any subconjunctival haemorrhage, it was not massive and got absorbed within ten days before he came for consultation. The appearance of the coloboma, the absence of gross iris tissue in the wound and absence of intraocular haemorrhage is suggestive of the inversion of the part of the iris. The colour of the scleral wound is bluish and is probably due to the deposition of the uveal pigment from iris as there was no evidence of cyclitis and posterior uveitis during the long period of observation. According to Duke Elder and others prognosis is good in one-quarter or one-third of the scleral ruptures. As a rule such cases have had a subconjunctival dislocation of the lens and retain aphakia vision. The present case belongs to this particular group. The vision last recorded was 6/9 with aphakic corrections. Normal visions after this type of injury have been recorded by Jeafferson (1871); Eales and White (1899); Rowan (1900); Schreiber (1904); de Schweinitz (1905): Cashell (1948) and Simkova and Zahn (1951).
A case is reported here of subconjunctival rupture of sclera and dislocation of lens in the anterior part of the globe caused by the strike of a jumping fish (Anabus Testudeneus) during the catch.
The vision in the injured eye improved to 6/9 with aphakic correction, about three and a half months after the accident. From the nature of the injury and from the history of the case it is suggested that the scleral rupture is an indirect one.
Our thanks are due to Dr. A. C. Mukherjee, the Superintendent of R. G. Kar Medical College for the permission to publish the case and to artist Sri A. Bose for the picture.
|1||Cashell (1948) Trans. O. S. of U.K. 68, 241.|
|2||de Schweinitz. Ophth. Rec. (1905) 14, 195.|
|3||Duke Elder, S. (1954) Text Book of Ophthalmology Vol, V1. Henry Kimpton, London, p. 5881.|
|4||Eales and White (1889) Lancet 11, 412.|
|5||Jeafferson (1871) Roy. Lond. Oph. Hosp. Rep. 7, 191. |
|6||Rowan (1900) Ophth. Rev. 12, 121. |
|7||Schreiber (1904) Munch. Med. W. 51, 1177. |
|8||Simkova and Zahn (1951) Cesk. Ofthal, 7, 109.|