Ophthalmoscopy, retinoscopy and refraction

Front matter

THE LIBRARY

OF

THE UNIVERSITY

Contents

Chai>tek Pages

I. Ophtlialnioscopy l-'24

II. Diseases of the Retina ^25-3H

Chapter II

Diseases of the Retina: The five colored plates that follow represent the commoner diseases of the retina, and they should l)e carefully studied with the ophthalmoscope in the model. The model should he made short, "hypermetropic" and the refraction carefully measured, then long, "myopic" and the refraction again measured. This should he done in order to acquire an idea of elevations and excavations, which must be done in order that a diagnosis can be made. This exercise will be found to be quite satisfactory upon the model.

It is the intention of the author to give the student and practitioner a working knowledge of ophthalmoscopy and describe a few pictures of lesions usually found in the fundus; the rare ones are not mentioned.

If the following pictures are carefully studied in conjunction with the use of the model, the student will be well prepared to make diagnosis of diseases of the fundus as he Avill meet them.

A beginner in tlie study of diseases of the eye is usually early in forming ideas regarding diseases of the fundus ; he begins as a rule by imagining diseases that are next to impossible. If the normal eye and gross lesions are well understood, the lesser lesions soon become simple. A greater number of diseases of the retina would only have a tendency to complicate tlie subject.

Detachment of Retins

Plate IV.

Detach:ment of the Retina: Plate IV. There is a large white crescent extending more than half around the nerve head ( Posterior staphyloma). The upper part of the fundus is red and the lower part is of a lighter color and is in folds.

The upper ])art a])pears red I)ecause of the choroid immediately under the retina wliile the lower part is of a lighter color, hecause the choroid cannot he seen, as the result of there heing something hetween it and the retina. The retinal vessels pass over the entire fundus hut the student will notice tliat they seem to he hroken at the edge of the detachment, or at the junction of the light and red areas. A similar picture is seen in sarcoma of the choroid, but a striking difference is seen when comparing the retinal vessels of detachment with those of sarcoma. ( See Plate X.)

A break will be observed at each told ot the retina in detachment, while in a sarcoma, breaks will be seen only at the junction of the light and red areas because of the absence of folds in the latter.

Tension : In detachment of the retina the eye is usually below normal.

Hyper:\ietropia: In both detachment of the retina and sarcoma, the affected areas are more hypermetropic than the normal part of the fundus. If unable to make a differential diagnosis between the two conditions by the a])])earance of the involved retinal vessels, the doubt can usually be easily cleared u]) by puncture of the sclera over the affected portion after cocainizing the eye. If the lesion proves to be a detachment, fluid will escape and the retina will be temporarily replaced in position as can be determined with the ophthalmoscope. Should it be sarcoma, there will be no change in position or size of the tumor.

Fig. 7. Detachment of Retina. Cross section Plate IV

Figure 7 represents a cross section of Plate IV. The student will note the elevation or hypermetropia of the detached portion. If the refraction is made with the ophthalmoscope at (A) and then at (B) without removing the ophthalmoscope from the eye, the difference in the refraction will be easily measured.

Elevation: When measuring the refraction of two portions of the fundus, a refractive difference of 3 D. is equivalent to a difference of 1 millimeter in level. The student will shortly become adept at estimating the height of any elevations or depth of any depressions he may meet.

Prognosis : Usually blindness.

Treatment: Rest in bed, laxative, sweats, potassium iodide, sub-con junctival injections of 1 to 3% salt solution or 5% citrate of soda; draw off fluid by puncture or trephine the sclera after laying back the conjunctiva and exposing it, after which the opening is closed with one or two sutures.

Retinitis Pigmentosa

Plate V.

Retinitis Pig:\ientosa: Plate V. The retinal vessels are normal and the scleral and choroidal rings are plainly visible. The background of the fundus is dark, spots of pigment are noticed, which are seen to be deposited on the retinal vessels. When the fundus is examined with the ophthalmoscope, the retinal vessels disappear first, when plus glasses are used, showing clearly that the spots are in the retina.T)

There is no difference in the ophthalmoscopic pictures of retinitis pigmentosa and ac(|uired syphihs; but the former always appears in childhood showing itself symptomatically by complaint of the early onset of darkness toward the close of the day, even long before normal individuals note any failure of the illumination. This symptom alone occurring in a child is sufficient for a positive diagnosis of retinitis pigmentosa without the ophthalmoscopic picture. External examination does not reveal any symptom of disease.

Figure 8 represents a cross section of Plate V. The student will note that the pigmented spots are in front of the retinal vessels and can easily be distinguished from choridal pigment by measurement of the refraction of one or more of the s])ots and of an adjacent normal area ^vith the o])hthalmoscope as described on Plate IV.

PiKKiXOSis: Blindness usually occurs about middle life or a little later.

Treatment : No treatment has as yet been found to be of benefit. However, errors of refraction should be corrected.

Fig. 8 Retinitis Pigmentosa. Cross Section Plate V.

Retinitis Pigmentosa with Oblong Disc (Luetic Retinitis) : Plate VI. This picture is produced in acquired syphilis; occurring only in adults and closely resembles retinitis pigmentosa.

The spots of pigment are plainly in front of the retinal vessels; whereas, if thc}^ were in the choroid, the vessels would be anterior to the spots.

Retinitis Pigmentosa with Oblong Disc.

Plate VI.

In observing the pictures in the model, the spots will be seen after the arteries have disappeared when plus lenses are introduced into the aperture of the ophthalmoscope, thus showing the spots to be on the retina. The nerve head is oblong to represent astigmatism, but it does not have any relation to lues.

Fig. 9. Luetic Retinitis. Cross section Plate VI.

Figure 9 represents a cross section of Plate VI and is inserted to impress upon the student's mind the location of the pigmented spots. The student will recognize that it is not a difficult matter to determine their location with the ophthalmoscope, it being noted whether the spots or the vessels disappear last when plus lenses are introduced into the ophthalmoscope. If the spots are seen after the vessels have disappeared while increasing the plus, they must be in the retina; and, if the spots disappear first they must be in the choroid.

Prognosis: If active but without too much destruction in the back of the eye, the ]:)rocess can often be arrested. If the lesion is old, the same treatment should be tried, but Avith less hope of improvement.

Treatment: If in a state of active inflammation, salvarsan or mercury and large doses of potassium iodide should be given : but if inactive, treatment of any kind is usually unsatisfactory. Errors of refraction if any, should, of course, be corrected.

Embolism Central Retinal Artery

Plate VII.

Embolism of the Central Artery of the Retixa: Plate VII. The nerve liead is blurred and there is a light area on its temporal side, covering the entire macular region, save for one small red spot. The patient gives a history of sudden loss of vision.

Figure 10 represents a cross section of Plate VII. The student will note that there is no

Fig. 10. Embolism Central Retinal Artery. Cross section Plate VII.

elevation of the fundus shown in the light area, as there would be if a tumor, exudate, or detachment of the retina were present. (See Plate IV and Figure 7.)

Prognosis: Blindness in the affected eye without any external manifestations.

Treatment: Massage, paracentesis and iodide of potassium have been recommended: but the results are usuallv unsatisfactorv.

Retinitis Albuminurica

Plate VIII.

Retinitis Albuminurica: Plate VIII. The

nerve head is not swollen as in choked (hsc, Plate XX, XXI and XXII, nor is it pushed back as in glaucoma Plate XXIII and XXIV, hut is pale as in atrophy Plate XVIII. The choridal vessels Avhich are wider than those of the retina, can be seen through the latter and tliere are hemorrhagic spots scattered throughout the fimdus.

The principal lesion, which is described as a stellate picture commencing in tlie macular region, is typical of this disease, is well marked and a diagnosis can easily be made by anyone who can reflect the light into the eye and illuminate its interior.

While this picture is particidarly typical, most of the pictures of albuminuric retinitis are not so much so. The student should examine the urine of any patient in whom the diagnosis is not plain. iMany diagnoses are thus made perfectly clear where only a slight lesion is found in the macular region.

Prognosis : Very grave.

Treatment: General treatment of nephritis but with no hope of restoring vision. The urine, tonsils, teeth, sinuses and a general examination should be made for the source of infection.

Chapter III

Diseases of the Choroid: The eight following pictures fairly represent the disease of the choroid. They should be carefully observed in the model and the refraction measured in order to be able to make the all important differentiation between excavations and elevations.

If these eight ]Mctures are carefully studied as described, very little trouble will be found in diagnosing diseases of the choroid when an examination of the patient is made: the author believes that more illustrations would only complicate the subject as designed for students and general practitioners of medicine.

Coloboma of the Choroid

Plate IX.

CoLOBOMA OF THE Choroid: Plate IX. The scleral and choroidal rings are well marked. The whole fundus is a normal red save in the lower part which is white. The strongest plus glass with wliich the screen can he seen on the red part of the fundus would indicate the refraction at that part of it, and the same measurement of its white portion would indicate the refraction at that point. If the red or normal part of the fundus measured the same as the white it could only be a coloboma of the choroid.

In this picture, the choroid is congenitally absent and the sclera is seen shining through the transparent retina and the retinal vessels are seen with a white sclera as a background. A coloboma of the iris is often found with a coloboma of the choroid, and presents the picture of a more or less complete iridectomy.

The student is reminded to measure the refraction on the red part of the fundus which is designated as normal and without removing his eye from the picture, to measure that of the white ])art of the fundus.

Figure 11 represents a cross section of Plate IX. The student will contrast tliis ])icture with figure 7 and Plates IV and X. Here there is no elevation above the normal, while Fig. 11. Coloboma of 1^ flgurcs ,5, 7 aud 12 the ele-

Sakcoma of the Choroid: Plate X. The scleral and choroidal rings are well marked, extending all around the nerve head, the upper part of the fundus is red and the lower part light. The retinal arteries are seen to course over the red part of the fundus where the choroid is giving the fundus its red color as well as over the light part below, where there is something between the retina and the choroid.

Sarcoma of Choroid

Plate X.

Hypermetropia: The sarcoma is always more hypermetropic than the red or normal part of the fundus. Compare with coloboma of the choroid (Plate IX), where there is a large hght area in the fundus but which is not more hypermetropic than the normal.

Vessels in Sakco:ma: There is a distinct l)reak in the retinal vessels at the junction of the red and light areas such as is found in detachment of the retina (Plate IV). After the vessels have passed on to the sarcoma, there are no hreaks as are found in the former.

Tension in Sarcoma: A sarcoma is not caused by low tension or soft eye as in detachment of the retina as it simply grows into a readily displaced watery body. The tension of the afiPected eye may either be normal or plus in the first stages of the disease. A sarcoma may become quite large without producing increase of tension, but later it always causes plus tension.

It is impossible to make a diagnosis of sarcoma of the choroid, without the ophthalmoscope, because the eye does not show any symptoms externally. If the vitreous and lens are clear the diagnosis is plain, especially with the use of the technique descril^ed for differential diagnosis under Detachment of the Retina (Plate IV).

Figure 12 is a cross section of Plate X showing the elevation of the sarcoma above the normal fundus. A, the elevation; B, the normal.

Fig. 12. Sarcoma of the Choroid. Cross section Plate X.

Posterior Staphyloma with Choroiditis

Plate XI.

Pkognosis : The growth may recur in the eye socket after enucleation, or in some other organ.

Tbeatment : The eye should be removed and with it as much of the optic nerve as possible, followed by X-Kay treatment. If the tissues around the eye are involved, all the structures of the orbit should be removed.

Posterior Staphyloma avith Choroiditis: Plate XI. The retinal vessels are normal, the scleral ring is very large, and the choroidal ring is well marked. There is a large light atrophic spot at the temporal side of the nerve head, (posterior staphyloma) ; many white spots are scattered over the fundus, and the retinal vessels seem to run over them.

The spots are all choroidal ; and, if the patient is myopic, the retinal vessels could be seen only with a minus glass. The student is reminded that in Plates V and VI the pigmented spots were in front of the retinal vessels wliile in this picture the vessels are in front of the spots. In those plates the lesions were in the retina; but in this pictiu'e the lesion is in the clioroid.

Prognosis : Rarely good.

Treatment: Glasses should be ])rescribed if necessary, but local treatment of the eye is useless. The urine should be examined and any general treatment tliat is indicated should always be given, having in mind the effects of lues upon the eye.

Disseminated Choroiditi

Plate XII.

DissEMiXATEJ) CiioKOiDiTis: Plate Xll. The scleral and choroidal rings are well marked and the nerve head is not swollen as in choked disc, (Plates XX and XXI), nor cupped as in glaucoma, (Plates XXIII and XXIV). The retinal vessels are normal. The only pathological lesions present are the atrophic spots in the choroid.

The sclera can be seen shining through the red choroid and the retinal vessels run over the atrophic spots.

Vision : The reduction of vision depends upon the location of the lesion in the choroid and the refraction of the eye. As long as the macular region remains free from disease central vision may be expected to be retained.

Prognosis: Grave if macula is involved.

Treatment : Constitutional treatment and correction of errors of refraction.

Rupture of Choroid

Plate XIII.

Rupture of Choroid: Plate XIII. The retinal vessels and the nerve head are normal. There is an atrophie spot with a pigmented horder at the temporal side of the fundus.

A diagnosis of rupture of the choroid, impossible at the time of injury because of hemorrhage into the vitreous, is made later from the ophthalmoscopic picture together with the history of injury.

Vision : Loss of vision depends upon the extent of the injury, and the location of the rupture. If it be on the temporal side, the loss of central vision will naturally be greater than w-ould occur if the rupture w^ere in some other part of the fundus.

Prognosis : Depends upon the location of the rupture ; the nearer the macula the less favorable the prognosis.

Treatment: At the time of injury two drops of 1% solution of atropin sulphate should he dro])ped into the eye three times a day together with such other treatment as is indicated. Potassium iodide is indicated for absorption.

Central Choroiditis

Plate XIV.

Central Choroiditis: Plate XIV. The lesion represented here is an extensive choroiditis. It occupies the entire macular region, and it would be impossible for anj^one to make a mistake in diagnosis, providing he had a working knowledge of the ophthalmoscope.

Such a lesion could be the result of trauma or any disease that would produce a choroiditis.

Prognosis : Bad as regards vision.

Treatment : None.

Central Choroiditis (slight)

Plate XV.

Central Chokoiditis: Plate XV. The scleral and choroidal rings are well marked and the retinal vessels and nerve head are normal. Three small wliite spots /ire seen on the temporal side of the fundus in the macular region. A diagnosis of central choroiditis can he made hecause spots in this region, either ])igmented or atrophic, are always the result of central choroiditis.

The fovea centralis is often very w^ell marked hut it is single and could not be mistaken for central choroiditis.

Vision : If the vision is normal there coidd not be a central choroiditis; but if the vision is reduced, a slight change in the macular region may be the cause of it.

Prognosis: The loss of vision is usually permanent unless a specific cause is found and treated.

Treatment: Entirely constitutional.

Injury

Plate XVI.

Injuky — Plate XVI. This picture is that of a perfectly normal fundus, save that a piece of steel has penetrated the eye, becoming embedded ^- in the sclera and is surrounded by blood.

A lesion in this location is not ordinarily as grave as if it were nearer the macula and produced by disease (Plates XIV and XV) ; but in this case, the prognosis is ver^^ grave because of the lesion liaving been produced by a foreign body, which has been retained within the eye ball.

Prognosis : Grave.

Treat:ment: Remove the steel with the giant magnet if the injury is recent and treat as any injury of the eyeball; sulphate of atropin 1%, 2 drops in the eye three times a day. If injury is of Ions: standing enucleate the eve. X-Rav examination shoidd be first made in all cases and foreign body localized.

It is not the purpose of the author to describe the treatment of injuries of the eyes; but it is always good practice to remove eyes that are blind and irritated, because the danger to the fellow eye is all important.

Chapter IV

Diseases of the Optic Nera:e: The following six colored plates with a consideration of the field of vision will give the student or ])ractitioner a good practical working knowledge of diseases of the optic nerve. Diseases of the optic nerve can often he diagnosed only hy study of the field of vision in conjunction with ophthalmoscopy.

iNIore pictures than are here described would have a tendency to confuse the student and complicate the subject.

A discussion of the method of taking a field will be given on page 76.

Glaucoma with Atrophy

Plate XVII.

Atrophy of the Optic Xer^^ with Glaucoma: Plate XVII. The scleral and choroidal rings are Avell marked but there is a marked difference in the size of the retinal vessels. AVliile the veins are normal, the arteries are noted to be small and threadlike. This condition alone would justify a diagnosis of optic atropliy: ])ut, in order to l)e absolutely certain, tlie field sliould be taken in each eye if enough vision remains to make it possible.

This plate also presents a ])icture of glaucoma, which condition will be taken up in a separate chapter, the cupping of the nerve head being shown by the apparent dipping down of the retinal vessels at its margins and proved positively by measurement of the refraction as described under detaclmient of the retina. (Plate IV.)

Prognosis: Of optic atrophy grave. Glaucoma, see page 71.

Treatment: Atro])hy-Salvarsan or mercury and large doses of ])otassium iodide may be tried : but, if a positive diagnosis of atro])liy lias been made, treatment is usually useless. Stryclinia is recommended by some.

If glaucoma, see ])age 71.

Optic Atrophy

Plate XVIII.

Optic Atrophy: Plate XVIII. The student has been cautioned regarding the color of the optic nerve in atrophy; but, in this ])icture the patient is blind which ])revents taking the field and the diagnosis must be made from the white disc and threadlike arteries. The veins are normal in size.

Field: If the patient can see well enough to permit the taking of the field, it should always be done in each eye. When a concentrically contracted field is found the student can be sure of his diagnosis no matter what the ophthalmoscopic findings may be. This rule should be remembered.

Arteries: If the arteries are threadlike and the veins normal as in Plate XVII, a diagnosis of atrophy can be positively made without taking the field ; ])ut it is wise to do so in all suspicious cases.

Prognosis: "N^ery grave: vision usually totally destroyed in time.

Treatment: Salvarsan or mercury and large doses of potassium iodide may be tried. Strychnia is recommended. ])ut treatment is usually of little avail.

Opaque Nerve Fibres

Plate XIX.

Opaque Ner^t: Fibres: Plate XIX. This picture is shown in order to describe opaque nerve fibres which, while they are of no significance, should be recognized when seen, so that they should not be mistaken for some pathological condition.

The white opaque nerve fibres usually follow the principal retinal arteries. This is a normal condition of the fundus of rabbits and is not infrequently met with in man.

In the human eye however, so typical a picture as is here shown is not frequently observed; more often the condition is present only in one or two areas adjacent to the nerve head where the vessels are covered by the opaque nerve fibres.

Plain Choked Disc

Plate XX.

Choked Disc : Plate XX. The nerve head is swollen and the diagnosis can be made positively because when the fundus is examined, the refraction is found to be higher at the nerve head than aAvav from it.

Hypermetropic Xerve: The student is cautioned to measure the refraction of the fundus in all cases at about one diameter of the nerve head from the nerve and when this is done, to measure it at the edoe of the nerve head. If the latter be more hypermetropic than the other parts of the fundus, a diagnosis of choked disc may be positively made.

It is important that the practitioner make a diagnosis of choked disc early because it is then usually amenable to treatment ; and if not properly treated, optic atrophy and blindness may follow. If the choked disc is only in one eye the cause may be found in the sinuses; but if in both eyes the cause must be looked for in the cranial cavity.

Figure 13 represents a cross section of Plate XX. The swelling of the nerve head can be readily seen.

Prognosis: Favorable, unless from malignant tumor of the brain.

Treatment: If the condition is unilateral, which rarely occurs, very often appro])riate sinus treatment will effect a cure. If l/ilateral and due to tumor of the hypopliysis, the gland should be removed. Usually however, the t^-eatment offering the greatest hope of benefit is the administration of salvarsan or mercury with large doses of potassium iodide.

Fig. 13. Choked Disc.

Cross section Plate

XX.

Neurorentinitis

Plate XXI.

Neuroretixitis: Plate XXI. The only difference between this picture and Plate XX, is the twisting of the retinal vessels and more swelling of the optic nerve. The nerve head is swollen and the retinal vessels are tortuous. The diagnosis is that of a lesion both of the optic nerve and the retina (Xeurorettxitls) .

Fig. 14. Choked disc. Cross section Plate XXI.

Figure 14 represents a cross section of Plate XXI. The diagnosis is readily made from the swelling of the nerve and the twisting of tlie retinal vessels.

Prognosis: Is the same as in Plate XX.

Treatment: Is the same as in Plate XX.

Papillitis Haemorrhagica

Plate XXII.

Papillitis Hemorrhagica: Plate XXII. The nerve head is swollen, the retinal vessels are twisted as in Plate XXI and tlie fundus is studded with hemorrhages some of whieh are lighter than others, indieating their more recent occurrence.

Fig. 15. Papillitis Hemorrhagica. Cross section Plate XXII.

Figure 1.5 represents a cross section of Plate XXII. If the media are clear, a diagnosis can readih^ be made and the amount of swelling of the nerve can be readily measured Avith the ophthalmoscope.

Prognosis: Is the same as in Plate XX.

Treatment: Is the same as in Plate XX.

Plate XXIII.

Glaucoma: Plate XXIll. The retinal vessels are normal in size but they do not emerge from the center of the nerve as in normal eyes, (Plates 1 and 11) but seem to stop and disappear at the edge of the nerve head.

If the eye is refracted, the bottom of the cup or center of the nerve head will be found to be more myopic than the surrounding fundus. The arteries may pulsate and the field is usually contracted and to the nasal side.

In such a case the tension may be high, the cornea anesthetic, the anterior chamber hazy and shallow, the lens clear, the vitreous clear, but the ophthalmoscope discloses this typical . picture of glaucoma.

Fig. 16. Glaucoma. Cross section Plate XXIII.

Figure 16 is a cross section of Plate XXIII; there is a pushing back of the nerve head. The excavation can be as readily measured as an elevation was measured in the other plates. The difference in refraction between the normal part of the fundus and tlie bottom of the depression will represent the depth of the cupping.

Prognosis: Guarded — seepage 112.

Treatment: See page 112.

72 OPHTHALxMOSCOPY, RETINOSCOPY AND REFRACTION

Haemorrhagic Glaucoma

Plate XXIV.

Hemorrhagic Glaucoma: Plate XXIV. Tlie retinal vessels are normal in size but do not emerge from the center of the optic nerve as in normal eyes. (Plates I and II.) They appear to stop at, and dip back from the edge of the optic nerve. (Plate XXIII.) The center of the optic nerve is more myopic than the normal part of the fundus and hemorrhages can be seen, some dark and some liglit, the latter being more recent.

Fig. 17. Hemorrhagic Glaucoma. Cross section Plate XXIV.

Figure 17 represents a cross section of Plate XXIV; the cupping can be readilv measured as in Plate XXIII.

Prognosis: Grave. See page 112.

Treatment: See page 112.

FIELD OF VISION Direct and Indirect Ophthalmoscopy