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Spontaneous rupture of the eyeball.

SPONTANEOUS RUPTURE OFTHE EYEBALL. REPORT
OF A CASE.
JAMES W. INGALLS, M.D.,
Brooklyn, N. Y.

On May 17, 1908, the writer was asked to visit a woman

suffering from severe pain in the right eye. In about half an
hour a message was sent saying that the eye had burst and blood
was running down the cheek. On my arrival, a short time later,
blood was oozing from the eyeball. Examination showed a
confused mass of clots and prolapsed iris protruding from the
lower segment of the cornea. The mass was estimated to be 10
or 12 mm. in diameter.
The following history was obtained: Mrs. C. E., aged eighty-
nine. For the past ten years patient has suffered more or less
from gout. Four years ago the sight in right eye began to fail,
and gradually grew worse, so that in the course of two years it
was nearly blind. Patient then went to an optician, who sold
her a pair of glasses "to relieve the strain," as he said. In
a few months the affected eye became entirely blind. Left eye
was apparently normal.
About an hour before rupture, pain was intense. So far as
could be learned there had not been any abnormal appearance of
the eye, except a dilatation of the pupil or "spreading of the
sight," as the friends expressed it. In all probability this was
a case of chronic glaucoma.
After rupture, patient suffered from shock, but did not com-
plain of pain in the eye. On May 23d, Dr. Jonathan S. Prout
saw the'case with me in consultation. A few days later, patient
was attacked with a severe diarrhea, which caused her death on
June 1, 1908. The relatives then allowed me to remove the
169
170 INGALLS: Spontaneous Rupture of the Eyeball.
eyeball. The report of the pathologist, Dr. E. L. Oatman, is
as follows:
Pathological Examination.-The eyeball is slightly collapsed.
Projecting from the anterior surface of the cornea is a black,
lobulated mass of prolapsed iuveal tissue, etc., measuring about
10 mm. in diameter. The base of the prolapse is constricted to
pass through a perforation in the cornea 4 mm. in diameter.
The eye has been the seat of extensive subchoroidal hemorrhage
which has produced total detachment of the choroid, retina,
and ciliary body, with consequent displacement of lens and iris.
These structures'are massed along the polar axis of the eye and
contribute to the prolapse described above. The scleral cavity
is filled with an old blood-clot. The prolapse consists of de-
generated uveal elements, lens capsule, detritus, and disor-
ganized blood. Its external surface is covered with a thin layer
of fibrous connective tissue, but not with epithelium. The
margin of the corneal perforation is smooth and the tissues are
condensed. Descemet's membrane extends to the opening and
for a short distance along its course. Degenerative and pro-
liferative changes in the retina, optic nerve-head, and uveal
tract which have resulted from the detachment render it im-
possible to state their condition previous to the hemorrhage.
Diagnosis.-Choroidal hemorrhage and spontaneous perfora-
tion of cornea in chronic glaucoma.
So far as can be learned, only five cases of spontaneous
rupture of the eyeball have been reported in ophthalmic litera-
ture. They are as follows:
Case I. Female, aged sixty-eight. Chronic glaucoma. Reported by Dr. B-
L. Millikin in Transactions of the American Ophthalmological Society,
1899.
Case II. Female, aged twenty-eight. Reported by Hauenschild, of Wurz-
burg, Ophthalmic Review, Jan., 1901.
Case III. Female, aged seventy-one. Chronic glaucoma. Reported by Terson,
Ophthalmic Review, Feb., 1902.
Case IV. Female, aged eighty-seven. Reported by Dr. W. Whitehead Gilfillan,
Medical News, Jan. 25, 1902.
Case V. Reported by Dr. James Moores Ball, "Modern Ophthalmology,"
page 418.
 INGALLS: Spontaneous Rupture of the Eyeball. 171
DISCUSSION.
DR. GEO. F. LIBBY, Denver: Last winter before the Colorado
Ophthalmological Society a case was shown by Dr. W. M. Carling,
which you may have seen reported, but as the final report has
not been published, I think I may briefly mention it. A woman
twenty-four years of age had recently experienced a spontaneous
rupture of the eyeball. In our Society the case was discussed at
great length, opinion being divided upon the question of whether
it was due to glaucoma or scleritis. Later, however, a typical
gumma developed at the seat of perforation. This gummatous
growth disappeared under anti-syphilitic treatment.
DR. F. H. VERHOEFF, Boston: From the number of cases I
have seen of eyes enucleated for expulsive hemorrhage I should
say that it is not so extremely uncommon for rupture of the
cornea to take place in these old glaucomatous eyes, but there is
usually first ulceration of the cornea. Perforation does not take
place until some time afterward. The remarkable feature of
this case is that rupture took place while the cornea was perfectly
normal.
As I pointed out several years ago, it is important to examine
such eyes very carefully to exclude the presence of choroidal
sarcoma. A sarcoma, although comparatively small, may un-
dergo necrosis and give rise to an expulsive hemorrhage. In
such a case the tumor may be difficult to distinguish from the
mass of blood filling the globe.
DR. W. K. BUTLER, Washington: I was surprised some time
ago to find that this -condition of rupture of the eyeball was so
rare. I saw a case occurring in an elderly person living in the
country that was due to an old glaucoma. The eye ruptured
from a large intraocular hemorrhage.
DR. WM. M. SWEET, Philadelphia: I have seen one instance
of spontaneous rupture of the globe in a blind glaucomatous
eyeball. The man, aged seventy-five, gave a history of a sudden
loss of sight in the right eye three years previously, which was
associated with severe pain in the head and with vomiting, the
attack occurring while he was eating dinner. The inflammation
gradually subsided, and the eye did not give him any further
trouble, but there was no return of vision. Two days before
172 INGALLS: Spontaneous Rupture of the Eyeball.
coming under observation the eye became watery, and the
following day, about twelve hours before I saw him, there was
a severe hemorrhage from the eyeball, which the attending
physician stopped by means of a pressure bandage. There was
severe pain at the time, but it ceased with the appearance of
the hemorrhage. At my first examination there was a hori-
zontal, somewhat irregular opening in the cornea, extending
from the upper outer limbus slightly downward for a distance
of 6 mm. There was no evidence of ulceration at the point of
rupture and the remainder of the cornea appeared healthy.
A large clot, which protruded through the opening, was cut off,
a pressure bandage applied, and the man put to bed. He
refused to have the eyeball removed. He remained in the
hospital for four days, there was no recurrence of the hemor-
rhage, and several months later the corneal wound had cica-
trized, but the ball was slightly atrophic.
The case is similar to others that have been reported, the
hemorrhage occurring in an eye blind from glaucoma. It was
impossible to find any ulceration of the cornea at the point of
rupture, but Coppez, in reporting a case, believed that the
corneal changes may be so circumscribed that the ulcerated part
may be carried away in the blood-clot. The lacrimation which
existed for twenty-four hours preceding the rupture may have
been due to some corneal disease. Villard reports two cases in
which the rupture was preceded by ulceration of the cornea.
DR. HIRAM WOODS, Baltimore: In reference to intraocular
tumors as a cause of scleral rupture, referred to by Dr. Verhoeff,
I saw a woman five or six years ago with choroidal sarcoma in
the outer fundus of the left eye. She was urged to submit to
enucleation, but declined. She attended the hospital irregularly,
then disappeared, and came back later with history of sudden
severe pain the previous night. There had been a rupture of
the sclera about 2 or 3 mm.. behind the limbus. Even then
enucleation was declined. When last seen, the patient presented
a large mass in the orbit. I mention the case in connection with
Dr. Verhoeff's remarks.