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THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES

OPHTHALMOSCOPIC DIAGNOSIS

OPHTHALMOSCOPIC
DIAGNOSIS
BASED ON

TVPICAL PICTURES OF THE FUNDUS OF THE EYE WITH SPECIAL REFERENCE TO THE NEEDS OF GENERAL PRACTITIONERS AND STUDENTS
BY

Dr. C.

ADAM

ASSISTANT AT THE KGL. INIV. -AUGENKLINIK, BEKLIN

TRANSLATED BY

MATTHIAS LANCKTON FOSTER.

M.D.

OPHTHALMIC SURGEON TO THE NEW HOCHELLE HOSPITAL: MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY; MEMBER OF THE AMF.RICAN ACADEMY OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY

WITH

86

COLORED PICTURES ON J>8 PLATES AND IN THE TEXT

18

ILLUSTRATIONS

THE MEDICAL ART AGENCY
Herai.I) Sgi arf. BcM.niNG
14i-14.,i

^
.'iihii
(
1

WEST NEW YORK

STREET
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REBMAN COMPANY
SOLE AGENTS

1913. by REBMAN COMPANY New York All Rights reserved PRINTED IN AMERICA .Copyright.

HI Co THE MEMORY OF MY HOxNORED TEACHER. JULIUS V. MICHEL .

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started from the clinical concejitions of disease. receive general recognition in his old age. it the word "Atlas" has been intentionally avoided. it many besides ourselves had ])reviously used in teaching in — was Ehchnig. Dimmer. have been utilized solely as a means of classification. concerning the material part played by tuberculosis in the etiology of diseases of the eye. to see the ideas. and that the attemjit on ophthal- has been made to bring out the diagnosis. SehmidtJtimpler. A glance at the Table of Contents show that the ophthalmoscopic pictures of hemorrhages. and the greatest consideration has been given vii to the varied needs of the general practitioner. l)ecause emphasizes the illustrations. the gynecolo- . text-book. the words "Ophthalmoscopic Diagnosis" have been chosen instead is in order to indicate that the real purpose of the book to be a systematic guide to diagnosis. for which he had fought all his life. Schiceiggcr. in The manner will which the text has been written and arranged has also been made sub- servient to this point of view. and that the illustrations are intended to serve simply as aids in the carrying out of this purpose. To a much is less degree is this true of his theory concerning myopia. and the writer well aware that he may excite in the title disj)ute when he undertakes to present this conception In the present book. with their details and symptoms. are now generally accepted as correct.. and others. and arrangement.Preface This book the credit of followed is dedicated to conception. He had His views the satisfaction. to wlioin I is due its liis its purpose. are Special attention has been paid to those diseases of the eye that related to general diseases. The first to take the ophthalmoscopic symptom as a basis for classification for doubtless — at least in literature. The earlier text-books moscopy. white spots. Mauthner. the neurologist. such as those by Jaeger. and to impress the clinical pictvire through the symptoms there depicted. idea in tlie nieniory of Jidlus its r. black spots. etc. in his article on ophthalmoscopic differential diagnosis his lead in Axenf eld's I have followed many places where his method of presen- tation seemed to be suitable for my purpose. Michel. as well as those in regard to the diagnostic importance of changes in the vessels of the fundus. which falls to the lot of few. and porti'aved these. the have sinijjly out bringing into bold relief relations that exist between diseases of the eye and those of the general organism.

vui gist. in tlio ni. hut they been reduced about two size for i-cproduction until they ])resent the inverted image magnified about ten times. nected with them form the oeidar Pathology nosis is entered into only so far as seemed advisahle for the explanaBrief space pictures is tion of the ophthalmoscopic pictures. and to thank my colleagues who have been of great assistance by selecting and furnishing me with patients. Krueckmann. I cannot conclude without expressing . likewise given to prog- and treatment.'inncr in wliicii tiiey arc presented.ition oplitlialmoscope. The reader will find in tlie tile Index not only the individual symptoms. Above all I wish to show my gratitude to Prof. f^^neral diseases of wiiieii tliev l)iit also consis^ns. helped my obligations to those who have me in this work. who undertook the great labor of revising the manuscript.ivi' of Thonicr's demonstr. tliirds in Alost of the were taken with the aid ii. and tlu' sypliilolo^ist.

. . 8. Determination of the Refraction) Place and Size of a Lesion in the Fundus The Dilatation of the Pupil for the Purpose of an Ophthalmoscopic Examination. Examination of the Periphery S 8 II. " Table of Contents PAGE The Technique of the Examination with the Ophthalmoscope I. Color Margins Normal Fundus ij 1 j The Ophthalmoscopic Picture of the Xormal Papilla 17 1 18 Excavation of the Papilla Vessels Arteries and Veins 18 23 22 2:i Venous Pulse Vascular Anomalies The Fundzis OcuH Types of the Normal Fundus Retinal and Chorioidal Vessels Retinal Reflexes . . -3 2i 21 2..) . 5. 7. 5 6 The Question of Wearing Glasses Avoidance of Reflexes from the Lens and Cornea Indistinctness of the 6 Image 7 7 7 Incompleteness of the Image Investigation of the Macula 9. •2. ^G -(>' Macula Conus and Staphyloma Differential Diagnosis of the 33 to be White Rings and Crescents diate Vicinitv of the Optic Xerve The Conus The Staphyloma The Conus Inferior Peripapillary Atrophy of the Chorioid The Halo Medullated Xerve Fibers ix Found in the Imme33 34 37 39 39 40 40 . Focussing upon the Papilla The Correct Distance Correct Accommodation 3 -t 3. 4. 6. 3 3 Invirled Imatje 1. 9 lU 10 The Normal Papilla and the AxATOMiCAL Review Form. Perspective Displacement. Upright Image Determination of the Differences of Level in the Fundus (Paralactir Displarement.

..' Cliarts 79 '** CiioKEU Disk l>c Uliat Etioloi/ical Conchisioii. 101 . 4. (jlaiieoniatons .. 53 53 55 55 55 57 Retinitis I'ijjnuntosa Simple Atrophy Nutritional . Etiological Conrliisions can be Drairn from the Ophthnlmoscojiic Picture of an 75 75 76 Optic I\'euritis ( Syphilitic Optic Neuritis Neuro-retinitis sjjecilica) 2.\tn)])liy 51 Atrophic Excavation 51 Total Atkophy 1. Optic NErniTis (Neuritis fascicuM liulliar neuritis) toxic neuritis.. 6. ^- Choked Disk ami Pseudoneuritis.\tiioi']iy of the Optic Nkiive Neuritis. 100 101 the Veins. 5. etc I. 3. 5.Vtrophy .iciilaris. b. The Caliber 1.Vrteries 3.\rteries Normal or Contracted The Differences in the Proportional Sizes of the Arteries and of Unevenness of Caliber a.X PAOE Atrophy of the Optic Nerve Differential Dia).m.Xtrojjhy Neuritic Atrophy Atrophy of the Papilla in 58 58 Pahti. AxiM. 4. Other Forms of Optic Neuritis III. Teimi'Ohai. //. Due to Oeeliision of the . retro'8 Demonstration of a Central Scotoma by the Aid of I^"./i/. Uniform Dilatation of the Veins and Arteries Veinous Hyperemia with the . 7i 71 Keuness of the Papilla by Itself Optic Neuritis Differential Diagnosis between Optic Neuritis. ^^ • • Contraction Dilatation ^8 '^^^ 2.Iul^i^ of the 5i Xarious I'Drnis of . 78 78 |)a|iilloiii. 73 71 Course of Optic Neuritis What 1. i.Vtro|)liy 2.i can Urairn from the Ophlhalmoscoiiic Picture of 81 Choked Disk Unilateral Choked Disk Bilateral 81 81 Choked Disk the Tumors Hemorrhages on Papilla 83 83 83 Wounds of the Optic Nerve Vessels of the Retina Preliminary Remarks on the Anatomy Changes in the Vessels of the Retina Elaboration of the Above 97 ^'^ ^8 ^8 Summary A. . 3. II. Tuberculous Optic Neuritis Albuminuric and Diabetic Optic Neuritis Arteriosclerotic Optic Neuritis 76 77 Otogenous Optic Neuritis Optic Neuritis Caused by Abscesses Accessory Sinuses Sympatlietic Optic Neuritis 77 in the Orbit and Emiiyeinas of the "i^ 7.

1. or the Is a Differential Diagnosis Possible. lOi 103 103 104 105 105 lOG Vessels D. 113 113 General Diagnosis Ophthalmosco])ic Differentiation of Diseases of the Inner and Outer Layers of the Retina and of the Chorioid 113 The Position of the Changes in the Retina . Change Based on These Findings? in the Retina IK! 117 117 Thrombosis of the Main Trunk of the Central Vein The Causes of Retinal Hemorrliage Differential Diagnosis 118 119 119 Recurrent Hemorrhage into the Vitreous b. Adjuvant Symptoms is Cases in which the Diagnosis Difficult 127 Question Is 2. this a Case of MeduUated Nerve Fibers or Not? 128 128 Diagnosis and Importance of Medullated Nerve Fibers Question 3. 113 Ill Retinitis Are Alterations C.25 Is the White Spot in the Retina. or in the Chorioid? Retinal and Chorioidal Spots) Trustworthy Sym])toms (Differential Diagnosis lietween 135 136 126 1. Hemorrhage into the Retina as an Accompanying Syinptiau of Disease of the 0])tic II. Hemorrhages Hemorrhages a. 2.j xi PAGE B. Changes in tlie Nnnilicr of the Vessels The Course of the Individual Vessel The Keflex Phenomena of I'ulsation \'enoiis and Arterial Pulse 106 Retina A. I'ltEI. in the Pigment Epithelium Present or Not? Ill II Special Diac. Most Important. Nerve in 1-0 While Spuls the Fundus Qucs/lon I. Of What Nature are the Spots in the Retina? 128 Question ).I. The Color of the Vessels 102 103 10-2 I Color of the Blood Column Color of the Vessel Wall Accompanying Stripes Transformation into White Cords Deposits in or over the C.MlNAUV ill KkmAHKS ON THE AnATOMY the Retina Ill The Nutrition of B.nosis Retinal Lesions Which Exliibit Xo Alterations in the Pigment Epithelium (Dis11 j eases of the Inner Layers) I. 110 as the Only. In How Far Can the Pathological Construction of moscopic Picture? a Spot be Determined fnim the Ophthal129 . F. E.

etc Masses of Pigment. I'ilirinoii. Bedridden. Ketir. Ketinitis Ketinitis leucocytliainica Ketinitis ana?inica Retinitis syiihilitica Retinitis proliferans In Cases of Choked Disk III. CKdenia. 3. XII PAGE nitfiTcntial Diafriiosis of White Spots from a Exudates) PatliolDgical Stanclpoint (Connective Tis129 sue. Gibhous Detachment Caused by an Exudate Detachment of the Retina Caused liv a Tumor of the Chorioid Glioma cf the Retina tlie 152 153 Concerning Prognosis as to Life of Diseases of the Retina and Cliorioid 153 Chorioid Prcliminiirii 167 Remarks Vessels cii the A ikiIo-kii 167 General Diagnosis of Diseases of the Chorioid. White Blood C)rpuscles 150 Necrosis of the Inner Layers of the Retina 150 151 151 Vasomotor Di. 4. 3. Bone Corpuscles. CEdema Diffuse Infiltration with 2. Marked Differences of Level 152 152 2. 4. 6.-oi:. Varicose 'Ihickcning of the Layer of Nerve Kihers. 133 133 134 135 135 135 133 136 149 149 149 lietinitis aibuminuriea ilialietica J. 7.itis Teptica) 13:2 b. Diffuse Oiiacilii of the Jirllim Without Great Differences of Level 1.s In How Far Can a Conclusion he the Etiology of Drawn from the Oplithalmoseopic Picture Concerning White Spots? Differential Diagnosis of White Spots from the 131 ( Etiological Stand. Fatty Degen- eration . 173 Ccneral Dinflnosis 1. 5. Diffuse Opacity of the Retina with 1. a. Fehrile Patients Xoufehrile Patients 1. a..ti3 Diagnosis . • SjirrinI Dkninosis in 174 Retina Which Occur Chiefly or Exclusively in Changes the Chorioid and the Peri])hery 174 CoUerlions 1 eif Pitjment 174 1 2.t a. 5. The The Are The Position of the Lesions in the Chorioid 173 173 173 Sort of Pigmentation and Depigmentation Changes Present in the Form of the Change of Level ^'essels or Not? 173 Differences 173 B. \\'hich are often Annular Snuff Fundus Isolated Spots of Pigment 74 175 175 175 . -'.(. 3. 1. 4. so far as They are Caused by Diseases of the 168 170 Etiology cf Chorioid. 17:2 3. 3.'turhance with Transudation Flat Detachment of the Retina b. 5.

The Disseminated Form of Fresh Spots Old Atrophic 1. in the i'erijilieri/ 175 Discrete Pigmentation Superficial 175 2. Changes 1.XIU PAGE Depigmentation 1. Pigmentation in 176 the Region of tlie b. Chorioretinitis 179 1 79 Sjiots 179 2. Atrophic Spots Without Visible Changes in the Vessels Atrophic Spots with Changes in the \'essels in the Chorioid with Differences of Level 180 180 181 Changes . c. 3. or by the Presence of Foreign Body in the Eye Changes in the Macula Caused by High Myo])ia So-called Coloboiua of the Macula Arteriosclerotic in Changes the 177 177 177 The Changes in tlie Chorioid about the Optic Nerve 177 178 178 178 Peri]>apillary Sclerosis of the N'esseN Hujitures of the Chorioid Coloboma of the Chorioid d. in the Chorioicl Macula a 176 176 2. Changes in the Macula Macula Caused by Contusions. 4.

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in J. after Ftichs —Schematic Sketch to Show how the Papilla Caused A. of Retina. IG 19 in 20 21 in 21 35 to I. f5. 38 I.—Choked Disk Q. — Variety H. — Neuritis Optica M. Text PAGE 5 6 8 —The Correct Distance — Correct Accommodation C. so that the PaOccupies the Bottom of its pilla Cavity 38 56 56 77 —Glaucomatous Excavation N.List of Figures in the FIG. 38 —In this Case the Ectasia Lies to the Nasal Side of the Posterior Pole. is Appear out of Drawing in High Myopia K. — Distribution of Pigment — Head of the Optic Nerve Myopia. Upright Image the Courses of the Retinal Vessels G. — Small Excavation F. P.ie — In this Case the Ectasia does not it Exactly at the Posterior Pole. 82 the —Anatomy —Total. after Greeff 112 153 Funnel-shaped Detachment of the Retina XV . but rather Below L. —Schematic Drawing of the Fundus. — Examination of the l^ft Eye D. — Microscopic Section Through a Normal Optic Nerve the Temporal Part of the Papilla E. — Deep Physiological Excavation O. R.

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XXI. XX. (i. VII. Conus Temporalis. 31. IX. XIV. Coiius I'emporalis 5. 158 158 45. XIII. Neuritie Atrophy Atrojihy of the Optic Nerve after Clioked Disk tllaucomatous Excavation and Atrojiliy : ()4 (U 66 <i6 16. . 27. Conus Inferior. V. XXTI. 30. XI. IV. Fundus III. l-\ i:i. Occlusion of the Central . 44. Vll. Large Physiological Excavation Atrophy of the Optic Nerve after Occlusion of the Central Artery Partial. XXIV. Media Conuuencing Choked Disk Conunencing Choked Disk Old Choked Disk with a Very Ahundant Develo])inent of Vessels Choked Disk at its Acme Occlusion of the Central Vein of tlie Retina (Aiiojilexia Saiiguinea Retina') Occlusion. 1. 39. 32. 42. XXV. 40. 26. Very Severe Neuroretinitis Alliuminurica Retinitis Proliferans in Retinitis Diabetes 144 144 1 i'' 1 37.List of PLATE I. 3. Commotio Retina-. VIII. -2. 2i. Plates PAGE Sti|ipli-il FIG. XXI.Artery in a Later Stage Flat Detachment of the Retina xvii 1«0 . XIX. -21. 43.. XXIII. or Thromhosis. XVI. VI. XIV. Proliferans in Syjihilis Retinitis Luetica The Same Case Six Weeks Later Sympathetic Optic Neuritis and Cliorioiditis Colloid Deposits on the Vitreous Lamella of the Chorioid Retinitis 16 148 148 l-5'> 41.. Partial Alhiuism MeduUated Nerve Fihers Simple White Atrojihy of the Optic Nerve Simiile Gray Atrojihy of the ()])tic Nerve Atrophy after Intlannnation of tlie Ojitic Nerve. VI. XVIII. Luetica the sivcalled XXIV. Paleness of the 0|)tic Nerve Optic Neuritis 68 (. 9.u-luuent of the lietina. Supertraetion in "Sehool" Myopia Commencing Staphyloma Postieum in "Congenital" Myopia Crescentic Sclerosis of the Chorioid H 46 7. XXII. 25. 33. 23. III. 28.'8 X. XXIII. 156 Embolism. XII. 17. 86 86 88 X. XVII. with Xiimerous Reflexes from Alliinotie 11. XI. XVIII. IX. 15. 34. 46. XV. 19. XVII. or Temporal. 50. N'ormal Fuuthis of the Tessehitecl Type. IV. the Retina Typo -8 -« 30 *^ I. 18. 38. XV. 35.36. of a Single Vein of the Retina Foreign Body in the Retina and Chorioid Retinitis Albuminuriea Retinitis Albuminuriea Neuroretinitis Albuminuriea Neuroretinitis Neuroretinitis 9- 94 94 1J2 122 1-H 138 1-58 '40 140 142 142 AUmminurica Diabetica Ciravidaruin wilh net. 8. 11. 10. XIII. VIII. 14. Tuhercle at the I'^ntrance of the Optic Nerve All>uminuric Optic Neuritis ( All)uminuric Choked Disk) Optic Neuritis Undergoing Involution The Optic Nerve in a Case of Sinus Tliromljosis Couijilicating an Otitis 88 ^0 9- 22. Due to Arteriosclerosis 46 48 48 Bi t'i V. I. 29. or Berlin'^ 0])acity Sudden Total Occlusion of the Central Artery. XX. Normal Fundus of the Unifonn. XIX.

xviii PLATE .

35 neuroretinitis. 6. 64 neuritis. 58. after choked disk. 47 Develo]inient of coiuiective tissue. 77 arteriosclerosis. 8 Chorioretinitis. 1. 32. 33 large gibbous. 37 Connective tissue rings. partial. 16 glaucomatous. 24 knob-shaped. meshes. albuminuric. 39 sudden. myopic. 3 67 Glaucoma. 14 gray. 64 myopia. 11 syphilis. 76 tuberculous. 51 simple. 16. 75. 60. 65.anguinea retina. 49 46 glioma. 14 retina. 51 Birling o]iacity. 45 Choked disk. 83 schematic pictures. 59-62. 5 55. 14 excavation. 17 white. 3 sti])pled. 60. 17 nenritic. 75 syphilis. 67 macula. 54 syphilis. 2 Conus inferior. 30 AjiO]ilexia -. glaucomatous. 70-73 peripapillary. inherited. temporal paleness. myopic. occlusion of. 44. 74. 1. 43 Central artery. 65.Alphabetical Index of Figures on the Plates The Numerals indicate the Numbers of the Colored Figures Alliinisni. 27 Arteriosclerosis. 59-62. 66. colloitl deposits on the vitreous lamella. 14 colobonia. changes of. 31 Alliuniinuric choked disk. temporalis. 14 Cilaucomatous atrophy. 77 stT. see Atrophy ditl'iise. 26 atrophy. 64. chorioid. 34 . 59-C'-'. 26 hemorriiages of retina. 68. Excavation. 44. 84. 69. 68 34 '27 occlusion of tlic central vein. 76 tuberculosis. 36 flat. 82. 50 in nephritis gravidarum. 20 abundant development of vessels. 78-84 Cilioretinal artery. 26 iiKi)>ient. 23. 5. 2j Chorioid. 48 partial flat. 63. 12 retinitic. 2 senile. 45 Cherry red spot. 68 macula. 69. 82 Diabetes. 36. 64-77 Glioma of Halo. Detachment of the retina. 75. 30. 70. 51 proiiferans. 64. 4 retinae. 10. 65. 70-73 Chorioretinitis. 84. 85 13" after occlusion of the central artery. 11 in retinitis pigmentosa. retinitis. 74. 8 4. 40 syphilitic. 64. 2 Lamina cribrosa. 58 tahetic. 36 white spots. neuritis. arteriosclerotic. 11 retina. 30. 56. 63 Depigmentation. 41 liemorrhage. 35 varicosities. 75 rupture. 55-58. 77 heredosyphilis. 47 caused by a tumor of the chorioid. changes reflexes. 33. 51 multiple sclerosis. xee Neuritis occlusion of tlie central vein. 59-62. 14 halo. 15 Foreign bodies in the retina. 53. 85 diffuse. 77 Neuritis 67 heredosyphilitic. 43 Connective tissue. 70-73 2. 14 physiologic. 29 Fundus.t its acme. 1 tesselated. Alluiiniiuiria. 76-80 59-63 albuminuric. 82 sympathetic. 35. 67. 50 Intravascular spaces. normal. 25 i. 7. 76. albinotic. 27 Atrophy of the optic nerve. ai'c neuroretiiiitis. 57. 65 ]ieripheral. 82 Coloboma Commotio of the chorioid. in. 10 yellow. 51-85 albuminuria. arteriosclerotic. acquired. 3 in myojiia. 78-84 vessels. 15 Macula. 73 jiigmented. liil.

allniininuria. 78 fibers. 3(i. Sj. miliary tnhercniosis. 12. 68 diseases of the vessels of the retina. 73 Weiss-Olto shadow-ring. H(i !) in the rahhit. 70-73 verum. 36. 22i Retina. 35. 54 Scleral ring. 59-62 Snuff fundus. Retina. (>. 31. 31 pigmented. 1 51. 39. 38. 63 Stajihylonia jjosticum. 39 retinitis. 27. 2\ defreneralion of retina. 36 striated. 37 3:?. i. 69 aneiiri^^m. 2 Scleral vessels. 56-58 depigmentation. 56-58 s\7>hilis'. JO lieniorrhages of retina. 44. normal. I-' interstitial. 1-9 21 . Jlyopiiu. tiilnTC-iiloiis. atrophy of the optic nerve. 75 "cordlike bundles of connective tissue. 42. 74. 34. 33 exudates. 2 Rabbit. 9. 37 degeneration in neuritis. 5 i)f diseases of the vessels selereetasia. 36 heredosvphilis. 16 (Tdema. 70-73 venim. chorioretinitis. 75. 73 . 18 tuhereulous. 58 diseases of the vessels of the chorioid. -'0 arteriosclerotic. 82. 2. mcdullated nerve fibers. foreign bodies. 18. 45 congestion through nedema. 52 white spots. 29 glioma. 73. atrojihy. 21. 70-73 injuries. 42 Tem])oral paleness. H see Atrophy (school). 31 diabetes. 56. sec . ]iictures of the diseases of the chorioidal vessels. 29. 22 Senile changes in macula. see Retina uiiil Chorioid Xeuroretiniti^. 18. 85 Sclerectasia. 58 hemorrhage. 56-58 finely pigmented fundus. see Atrophy changes in arteriosclerosis. 32. i6-58 white spots in albuminuria. see detachment. 15 transversely oval. 32 12. 30 retinitis pigmentosa. 44. 24. 20. 73 Stipjiled fundus. 8 Peri]iapillary (inlema. 2-2 svpliilitic. 36 alhuminurie. aequirecl conjrenital. see Neuritis Pigment. SO 22. 55 snuff fundus. 28 uberculosis. 27. 12. 63 occlusion of the retinal artery. 73 occlusion. 32 Vena Vortex Weiss-Otlo shadow-ring. 81 iliiltiiile si-lerosis. 9 Neuritis Thrombosis of the central '1 vein. 38. 78-84 centralis. 3 56 26. 19. extravasation of vessels. -10 Occlusion of the central artery. 37.5. 45. 1 Supertraction crescent. . 40 Syphilis. 6. 31. 27. 51 jiroliferans. 27. ()7 diabetes. degeneration. -0 in otitis media. 2. Neuritic atro|iliy. 39 sjinpathetic. 17 'iesselated fundus.XX McthiUated nerve M(IliIl}riti^. 3. 35. the chorioid. 7. 45 Otitis neuritis. 28. 40 Papilla. 30. 28 veins. see also Neuroretinitls albuminurica. 38. in neuritis. 1. 37 diseases of the vessels of the chorioid. 31 Nephritis. 30 in diabetes. 75 rings. 2ii. 83 migration of pigment. atrophy of the optic nerve. through niedullated nerve connective tissue. JJ 18 -21 Retinitis.31 normal. 49 disajipearance of vessels. 1. 43. 84. fibers. 34. 44 reflexes. 38 inherited. 58. navus. 33. alliuminurica. 28. 81 Miliary tuherculosis. 76 diseases of the vessels of the retina. 55. 3(j 33. 63 grossly jiigmented fundus. 5 S3^llpathetic inflammation. migration. 66. 3i. 42. 53 l)e))per and salt fundus. jieripajiillary 84- Schematic oedema. 85 Sclerosis. liiabetic. dis|)ro])ortion of vessels.\lbnniin\iria Neuritis. 81 undergoing involution. 52 syphilitic. IJ 21. 39 fatty degeneration. 51 Naeviis of retina. 3(i atrophy of optic nerve. see tilso Neuroretiiiitis vessels. 28. 85 sta|)hyloma iiostiemn. 57. 16. 36. migration of pigment. 37 se<'oiuiary iiigmented. neuritis. 50 sy])liilitic.

Preliminary Remarks on Technique .

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if it is on the other side. so as to read: to look at a distance past tin- In order to present his papilla the patient ear of the observer corresponding to the eye that is being examined. him to look not at the but past as though at an object in the distance. It is therefore necessary that on the side on which the phA'sician holds the mirror the patient should look the observer. to the nasal side of the macula. may mirror is about right. in order to bring his papilla into view. to direct it. he shoidd look about a handbreadth i-ision aicaii from the ear. because he then accommodates. if the latter is on the side on ichirh the phi/sician holds the mirror. Focussing upon the Papilla. while the distaiice from the left ear to the confront the observer. ear of the observer. but not upon that of the right.e.5 cm: it is a handbreadth. 15 cm. in order that the papilla. of the observer.ir. which But when the physician holds the mirror before his right eye. INVERTED IMAGE 1. in full detail in but a few suggestions may be of aid to those who are inexperienced. some 10 cm too short. it is not advisable to have the patient look at the ear of therefore better. and a contraction of the pupil accompanies acconnnodation : it is when the patient c.. that he should look at the corresponding The object of this direction is to cause the patient to look past the eye i. but ])ast it not at the car of at the distance of about a handbreadth. at a certain distance. 3 . The is direction usually given should therefore be made more precise. light should be placed behind The it will and to the in side of the patient. the distance between it and his right ear is considerably less than the requisite 1. with his own lies eye slightly inclined toward his nose.The Technique cannot be taught of the Examination with the Ophthalmoscope such a book as this. or the mirror. so that not shine into his eye. I. even the observer. The reason for this is too literally the customary direction. Furthermore. the line of should pass close to the ear. is The complaint heard very often every class in ophthalmoscopy that that the patient obeys the student can focus quite well upon the papilla of the left eye of the patient. is sitting on the opposite side.

is When a +13 D lens ^ is used the distances are as follows: The and the total distance between the physician and the patient approximately This pro- 40 to \h cm (see Fig. the patient presents his papilla cori'ectly the pupil does not appear to be as it otherwise does. l!. which may interfere with the If examination red as color is . is of paramount importance. lens. to interrupt the examination and to first ascertain of tdl -iciutlicr the position of the patient's ctjc in :it is correct. The distance at which the latter must be hold from the paper in order to obtain a sharj^ly defined image corresponds in general to the focal distance. or to an incorrect. which is measured in centimeters.The correct presentation of tlie pajiilla is a matter of tlie f^reatest iinporis it tjince.v producing the picture of any source of light upon a piece of paper by means of the lens.'hich Hincc papilla is it should be tlic rule in nil cases in the attempt to see the not irnmediatel// successful. The Correct Distance between the optical systems. eye — — lens ej-e. not much larger than the head of a pin. . zs. or inexact presentation of the papilla. If the image is sharply defined at the distance of 100 5 cm the lens is r= 20 diopters strength. After the patient has been told at first closes what direction to look the observer the eye which is not the ophthalmoscope and throws light into the eye of the patient without this he learns the iiiter]>osition of a lens. Ixcause the tone of papilla. vided that both the physician and the patient are emmetropic. or opacities are [)rescnt in the cornea. f If either one convex lens may be ascertained in a very simple manner b. but is of a whitish yellow. attain this end 2. of which 7 lens cm are between the patient is 32 to 37 cm between the and the physician. It perhaps the most importiint point connected with the examination. to be ascribed to an incorrect. the lenses are numbered according to the metric system) in order ^ The strenprth of a ^ to learn its strength in diopters. A in the text). or vitreous. 1. is and it will appreciated that a considerable degree of accuracy in tlie necessary to properly present this point relatively large surface. whether the refractive media are clear. or inexact Let it once be realized that the retina comprises an area of several square centimeters. althougli it is generally uiulervahied by beginners. for without exaggeration that in may be said about three quarters of is all the cases a failure on the part of anyone using the opiithalmoscope direction to the patient where to look. that within that surface the papilla is i)e only a minute point. lens. whether the papilla is actuall}' before him. is its determined by that of tlie When To this has been ascertained to be the case a lens placed before the eye and the observer tries to obtain a sharply. By doing two things: and. Then it is only necessai-y to divide 100 by this number (100 cm 1 m.defined image of the papilla.

and then comes the micrometer screw. while a hypermetrope has to increase . A myope lessens his correcting glass by the same amount. In high degrees of hypcrmetropia. First comes the gross presentation at the distances given above. and the accommodation used for reading is called into activity. of the fundus produced by the convex lens lies in it. Correct Accommodation. 7 cm in front of at point B in The physician must focus his eye upon this point. a. like such as are present after removal of the lens for cataract. the observer must increase the distance quite a good Fig. deal in order to obtain a distinct image of tlie fundus (see Detaclmient of the most important the Retina. front of the latter at the distance of its focal point. page 1-52). do best without any correcting glass. if either cne or both are quite hypermetropic the distance must be somewhat greater. U.or both have over 4 D of myopia the pliysician must come tlie closer. preferably behind the mirror. Next to faulty accommodation. incorrect distance (>)• is cause of iiuiistinctness of the image (see under 3. by the movement of the head of the physician a little backward and forward until the image is sharply defined. We must proceed in a manner similar to that employed in use of a micro- scope. An emmetrope can overcome this difficulty by substituting for the necessary accommodation a convex glass of from 2 to 4 D.5 to 30 cm. But beginej'e of the patient. accommodate and so cause the image to be indistinct. This is done most easily when the point is at his ordinary reading distance. "2. so that myopes of less than 4 D ners usually try to see the image in the incorrectly. The image Fig.

The Question of Wearing Glasses during an ophthalmoscopic examination has been answered by the above ri'inarks. fixes his eyes it is T em in front of the lens.in the shade. particulaily if he is presbyopic. B.s been said is tliat the observer must be certain regard to own refractive condition. even by the most expert.. for the disturi)ance they cause is due not only to the fact that they cover the image. Fig. 4. for a dirty lens increases enormously the reflexes that appear.the strength of his glass. It is well for the {)h_vsieiaii to euiaiieipnte iiiinself from tlie need of tliis is glass by prolonged praetice. Avoidance of Reflexes from the Lens and Cornea. the lens a little directly on the He may partially succeed in doing this by moving to the right or left. the ordinary reading distance. the observer iiis on the tij) of the finger and maintains ucconmiodation when witlulr. Sometimes the reflexes come from other sources of light this may be guarded against by seeing that the only light in the room is the one used for ophthalmoscopy. reflexes These can never be wholly avoided. Finally. and that this is placed obliquely behind the patient. Much is won when he learns to look past the reflexes. of his finger at the place where the image must be formed. . but also to the fact that they distract the attention and consequently excite a faulty acconnnodation ill the eye of the observer. or by holding the lens in a slightly oblicjue jjosition.e. A in corollary to what his ha. ti|) Anotiier trick to have someone hold the i. The most convenient way to jilace a glass of the jjroper strength behind the mirror. 5. the lens itself must be perfectly clean. so as not to look directly through its center. 7cm~ Z5-30cm. the physician wears the same glass that he uses to read is witli. As the image lies in front of him at the distance of 25 to 30 cm.iwii. . fall The student nnist learn to place them so that they do not place under observation. so that the eye to be examined is altogethei.

faulty. doing this the rules should be observed that are given on page 11. the observer Jias not siiceeeded in seeing best for him to break off tite tlie papiUii. The macula must move papilla. accommodation may be and may need to correct Given under 2. 4. positive that the cause lies neither in himself nor in his technique. Opacities may be present in the lie throws light into the refractive media. Indistinctness of the Image. the latter moves head very slightly to the right. 3. while the latter remains looking is the same direction as during the presentation of the tile also possible. wliile eyes retain tlieir relative positions. Init not the whole.6. therefore know the re- may have high degree of astigmatism. 7. Of course the same result could be obtained by having the patient look a little more to the left. The Investigation of the Macula is often tiie difficult. or anfi portion of the patient it. of the papilla comes into view. If only a j)ortion. 5. The His distance may be incorrect. fraction of l)oth liimself and the pa- or of some other error of refraction. in spite of (lU tliis. 2. only the left side of the papilla can be seen from the standpoint of the observer. to redireet how to look (see under 1). and to examine the eye when in a condition of mydriasis. Therefore it. has huun caufrlit of the jiapilhi it often appears to be very This may be due to a variety of causes. retina. Cause 1. . 8. Incompleteness of the Image. even for the it expert. for the physician to move the lens toward the patient's nose until the macula appears in its temporal margin. or the phvsician own eye in into the line of vision of the patient. it is examination. the examiner moves himself toward the patient maintains his line of regard. sicrlit AfttT indistinct. his //. side which he wishes to if see. Given under 3. optic nerve. wiiile the For example. It is so placed that in order to bring in it into view eitiier the patient must look at the aperture his the center of the mirror. so there should be no iiesitation to dilate pupil wlien cannot In be seen clearly. Bemcdy or the patient Tlie jiliysician He must tient. Tlie indistinctness tlie may be due The beginner should not make diagnosis until he is this to disease of etc. eye without using a lens before trying to see the fundus. but the obsei'ver usually has his own movements under better control than those of tiie patient. and to try again.

Sig. solution of honiatropine. solution of cocaine. and The ])atient . in the per cent. hydrochlorat ().0 M. ever keeping in view the red . ]^ Coca in. so that he can direct the movements of the head as desired. interposes the glass that corrects his own refractive it error plus that of the patient. W cm left a])art. whose head forward at the same time. he presses a little throws the light into the eye to be examined. then takes the ophthal- FiG. down. The fundus can be seen in this way to within . 0. One drop in the ej'e. The latter places his left hand on the right shoulder of the patient. Sig. taking for an example an examination of the left eye. in his right hand. For the Examination of the Periphery. piitiout is told to look up. One drop in the eye.. hydrobrom.1 Aqua. tlie which must ri<jlit.0 ad 10. UPRIGHT IMAGE lie Tlie difficulties in the wa^' of an examination of the uprii^ht imawe tlie in reiuxation of the accommodation and the management of the light. should be placed eye half an hour before the examination. to the .5 mm of tin- miliary body. holds before his mination of the pupil.\(|ua' destil . C.should be told to fix his eyes on a point in on the wall situated with the the prolongation of a line connecting his left eye eve of the physician.'3 II Ilomat ropiii.•uid to thu kft. and sees the red illu' Now he slowly approaches the patient.. Examination of the Left Eye The about light should be plactd near the Kft side of the ])atient on a level with his eve.. The following method seems the best to me.destil ad 10. ikvui- be omitted.8 9. approximately at least. . II. or of a 1 When practicable a drop of a 3 per cent. ^M. The physician and the patient should lie seated on a level. moscope left eye. or rather somewhat about the neck.

little a glaucomatous excavation.9 illumination of the pupil to and making it bright again. By the so-called Parallactic Displacement. than those situated farther away. or if the physician wishes to look at another part of the fundus than that directly before him. If the image is not (juite Success is usually obtained after a few efforts. as when we use the ophthalmoscope. convex lens moved back and if the details of the fundus seem to level move against one another differences in are present . forth a little. By from the Perspective Displacemsnt. the left left. draws quietly back from the j)atient and repeats same maneuver. Thus the eye of the physician and that of the patient approach each If the observer has not lost the light in its other until they are only 1 cm apart. a lock of hair. and so to determine the correction. The patient should continue throughout to look quietly in the same direction. this kind of Still we can distinctly recognize out of the question. he moves his head in in the direction opposite to that which the part lies which he wants to see. he looks at the fundus through the pupil just as he would look into a room through a keyhole. the papilla suddenly appears before him If he has lost the light he perfect beauty. while the observer watches until a sharply defined image of the papilla is obtained. In other words. 1. the parts nearer the observer seem to be displaced more. If the This is is noted during the examination of the inverted image. If it is lost again at the same place. to side When in the observer moves a side is during an examination of the u{)right image. the cause may be an insufficient rotation of the mirror. ordinary differences of level in various ways. is examined its in this way the impression given that margins are slid forward over base. on the way. and vice versa. the the opposite. or tlie position He corrects the fault. when he wishes to see the right side he moves his head to the left. The best way to do this is to look constantly at a certain blood vessel. distinct the lenses in the ophthalmoscope are slowly changed for stronger or weaker ones. by little rotations of the mirror. The with the right eye should always be examined with the right eye. If the entire papilla is not the either seen. while those impression farther given that the nearer places move in awav move the same direction. whenever it threatens become indistinct. and begins again. DETERMINATION OF DIFFERENCES OF LEVEL FUNDUS AVe perceive depth in IN THE we can see with only one eye is perception of depth life bv means of binocular vision. but. or to move more its rapidly. is When 2. and the is light should always be on the same side of the patient as the eve that being examined. . of the light. whatever it may be. for examjile.

Hence.75 nun. i.e. we have as order to sec those that are detached. that diam- 0. we have to lean far back the indirect method.n of the I'etina: whiK...'ck. its we say that the eter is size of a lesion is it a papillarv diameter.uts that tiii' come i.") nnn. and then the normal portions the observer draws rather near to a))pcar to be bright while the detached parts are dark. and vice versa. THE DILATATION OF THE PUPIL FOR THE PURPOSE OF AN OPHTHALMOSCOPIC EXAMINATION is. as ti'e the case in a bullous detachment of the retina. the different parts of varying distances. and is it is to be recommended whenever the examination pupil. in detachment of the retina. is the thrown into the eye. under certain precautions. or that lies 2 papillary diameters from the temporal i. or perhaps the detached bulla can be distinctly seen. 3 mm distant. is When the dift'erence of level very great. as in aphakia. an absolutely harmless procedure. we know that the papilla 4. By tlie Determination of the Refraction Tins also is is < f the p. ddiu' in llir rxaiiiiiial ion of iiprifjlit iniafrc. It fundus can be seen at has been mentioned that in in high hy|)ermi tropia.e. In evei-y case has a lower deiirie of refraction than those portions that farther li. 5. We indicate the Place and Size of a Lesion in the Fundus by its reference to the papilla and diameter.'J 1) corresponds to an elevation or depression of is nnn. for exanipK. b'or example.a choked disi'.the parts that are not detached can be to lean very far seen at the normal distance. into question. It is better to rendered difficult by a small It is make an exact diagnosis with It is a dilated pupil than to is make an incorrect or incomplete one because the pupil too small. raised 1 mm is aljo\e the retina. is F{)r example. often almost essential for . especially if the eye.'5 if the retina of an eye ennuetropic and the is jjajiilla liypernietroj)ic 1). such a part will witii its vpci'inctro])ic is and form a contrast the elevated lie emmetropic surroundings. no confession of incompetence or ignorance. order to see the fundus distinctly by This is the case to a much greater degree back in with the detached j)orti(. in A dift'ei-ence in level can le calculated in millimeters from the difference nfraction. in is an otherwise emme(rreatly elevated so l)e ii tropic eye a certain as to lir j)ai't.e. in comparison with an eimnetropie. all other conditions Ijeincf the same.. A its hvi)crnict ropic eye too short. ch)scr to the eve of the ohsrrvcr. can often oi' be percei\X'd better by sim})le illumination than bv either the direct uidirect method. . hen retina is nearer to tlie eye of tlie observer than that of an emmetropic ^^ eye. which ^ •• i> 1.10 3. tiie If the eye myopic the elevated part will he less so tlian |)ai-t rest of tlie fundus. margin of the disc of the optic nerve. for a difference of refraction 1 of . Great differences of I>ight level..

drops of homatropine may readily be used. Sig.1 1{ Cocain. while this is it interferes with the view into the Two. One drop to dilate the dilate the pupil. but also the acconnnodation for about 8 davs. The accompanying disturbance of the accommodation is therefore comparatively slight. XoTK. Four or five hours later the pupil has usvially regained its normal size. an exfoliation of the epithelium of the cornea may readih' be induced by the application of many drops e3-e.11 the use of the direct method. One or two drops to M. or tlie examiiiiition of the macula.3 ad 10. and these are: ])uj)ils Never use atropine to dihite the for this purpose. What 2. as they inmiediately escape. The patient is sent back into the waiting room and half an hour later we see if the pupil is dilated. Aqu. . because fairly harmless.0 Aqua. 0. Not more than one drop of the mydriatic sliould he placed in the ej'e of an old person. . In the latter case it is best not to use any mydriatic at all it is often superfluous. because renders paretic not only the sphincter pupiUa'. Tlie mydriasis begins after about 10 minutes and reaches its acme on the average in half an hour. and. . or even three.e destil !M. hych'obroni. The only it thin^ necessary 1- is that certain precautions he ohservcd. It is of no use to instill a large number of drops. and if there is any suspicion of glaucoma. except in cases of glaucoma and in old people. The method is to draw down the lower lid with the forefinger of hand and to allow one drop of the solution to fall gently upon the inner surface of the lid from a dropper held in the right hand. that are somewhat dilated and react badly to light. another drop is instilled and the eye is seen again 15 minutes later. Usually it is if it is not. hydrochlor 0. The most It suitable mydriatics are: . that means is readily appreciated by a pliysician who has once instilled atropine into his own eyes by way of experiment.0 Sig. of instilling the drops left the . so that the patient is unable to read or write for a week. as patients with glaucoma usually have pupils .destil ad 10. Homatropin. . Care must be exercised in the case of old people. especially when cocaine is used. — Not more tjian a single drop of cocaine should be used. pupil.

.

The Normal Papilla and the Normal Fundus .

.

of the ophthalmic artery. It is composed of nerve fibers. or the sclerotic. to those of the brain ventricles. The nerve fibers form bundles that run parallel to one another. and pial membranes. in the intraorbital portion of the optic nerve. the anterior and the posterior. the and connective tissue. anterior segment it in is which enter the lower medial quadrant. and cjiorioid. facial vein. The optic nerve is to be considered as a portion of the brain that has like been projected forward. it is enveloped in 3 sheaths. This nerve enters the eyeball througli the lamina cribrosa of the sclera. the lateral in the dural. and there forms the papilla. Two The segments.Anatomical Review essential in A brief review of the anatomy is order to understand the ophthalmoscopic picture of the papilla of the optic nerve. is this plexus gives off branches to the optic nerve a connection formed between the vasis cular systems of the retina and the chorioid. These vessels form Zinn's. and. the latter. posterior segment receives its blood supply from a long. may As be seen on transverse section in the neighborhood of the place where this change occurs. connected with the A number of vessels. recurrent The branch of the central artery of the retina and other branches of the ophthalmic artery. while the inner one enters its innermost lamella. and are interlaced together by an interchange of number of wliicli lias been estimated 15 . and discharges its blood into the cavernous sinus. need to be differentiated supplied by the central artery and vein of the retina. which turn is a branch of the internal The vein empties into the cavernous sinus. or into tlic superior and has numerous anastomoses with other veins in the orbit. or a branch. and then run axially in the nerve. carotid. The artery comes from in the trunk. because of the vascular supply. to the inner side of and a little below the posterior end of the optic axis. 10 or 12 mm from tiie eyeball. The optic nerve about 4 is circular on section ni its fibers orbital portion and is mm thick. vascular plexus. the interspaces of which correspond and are furtlicrmore connected directly with the This fact explains how it is that an increase of pressure brain is transmitted into the optic nerve to produce a choked disc. The two is outer sheaths pass over into the two outer layers of the sclera. arachnoidal. but this union of no practical importance. which surround the optic nerve and are fed by the posterior short ciliary arteries. which forms the lamina cribrosa.

join to form a ni'twork. t siibst. lU'rve. sends numei'ous i-aiiecul. of Srincinni. fibcis. but no sheatli ami a supportingTlie pial siuatli. closely adherent to the surface of it.-i' and srpla into wliiTe tliev .16 at half a million. The nerve fibers have a medullary sheath.uicc uliieli is composed of neuro^-jia tissue lies between tlie tiiem. and to invelopi' the bundles of nerve are to be found the lymphatic and blood vessels. \\'itliin these " .

The color of the p. as at the temporal margin. or slio-htly oval vertically. excavation or protrusion. but is produced by an astigmatism of the cornea. If this . are particularly' nasal margin in At the places where the fibers and densely packed. in hypermetropia the papilla seems indirect method. the reverse myopia smaller. those places in which the optic nerve fibers are almost wholly wanting. 2. THE OPHTHALMOSCOPIC PICTURE OF THE NORMAL PAPILLA The followinn. points luive to Ik- noted. On the contrary. which are slightly gray. for example at the the upright image. must normally be white. The Form Ia'ss of the normal papilla often it is usually round. The Color is results from the combination of that of the lamina cribrosa fibers of the optic nerve. over which pass the few supply the macula (see Papillomacular bundle). an indication of atrophy. this indicated by a true white color. or obliquely oval. 1. seem reddish from the presence in them of numerous well capillaries. a peculiarity which does not usually correspond to an actual anatomical condition. to be larger. 2. At the same time is true differences in size are met with. Form and Color. Margins. who myopia. except for the apertures. level. appears to be horizontally. the color of the lamina cribrosa. therefore. 5. 3. in The variations in size are also only apparent as a rule. the center. Conditions of Vessels. which corre- sponds to the excavation about to be described. when examined by the when seen by the direct. with the sometimes include a circular staphyloma. in a systematic examination 1. and its meshes with that of the almost transparent The former almost white. which have a gray appear- ance. size. The temporal side (upright image) is usually brighter than the nasal. as at the bottom of an excavation.i})illa is also influenced by its environment. the paj)illa appears redder tlian where developed they are less in number. Attention may be called here to a mistake often made by beginners. while the optic nerve fibers. one after another. The observer sees through the almost transparent fibers to the lamina. nerve and are led to think that the papilla The a little color of the papilla is a delicate red which might aptly be compared to that of a peach blossom. is In a large number of cases a specially bright spot to be seen in. is and delicate fibers that The brighter color of the temporal side is not. or a little to one side of. in is congenital enlarged. sometimes the papilla in the "little" unusually small hypermetropic eyes (see under Pseudoneuritis).: 17 A. 4.

as a rule. I iti This happens more often in myopic th. on the other hand. as number of nerve fibers that reach the normal eye. Special marginal rings are frequently present. Excavation of the Papilla. As it must be supposed that there cannot be any excessive difference in the also affected by age. It is exceptional cases that these circles are complete. because of the relatively denser layer of bundles of nerve fibers with the capillaries between them. papilla dates back to the time The name elevation at the entrance of the optic nerve. and these are usually on the temporal side. shines quite weakly through the tissue as a yellow crescent. The nature of the light. the yellowish tone is apt to be acquired in old age. 1). is The margin more distinct on the temporal side than on the others for the reasons usually devel- already mentioned. likewise exerts a certain influence. and sometimes one or both of the rings Sometimes the chorioid. is looks redder when the fundus particularly pale. when it was thought to be an This was an erroneous anatomical . The margin is of the papilla. youth the red prevails strongly. but otherwise there tissue ring may only be seen in first a connective and then a ring of pigment. 5). I in the text). and one black. and. produced when the pigment layer of the retina in the neighborhood of the optic nerve is particularly thick and this thickening The black ring stands out prominently. the optic nerve it will seem to he particularly bright from contrast. so that this appears thick and indistinct (see Fig. segments only are visible. size of the papilla. separating the sheath of the optic nerve. the supertraction crescent (see Fig. as the papilla appears to be paler or redder in in proportion to the number of red rays It is it contains. that is. 3. the portion of the optic nerve that covered. The Margins of the normal papilla are sharply defined. retina and sclera are pushed over the nasal margin of the papilla. Age again plays a certain part. frequently there is an accumulation of pigment instead of a black are entirely absent. as in brunettes. or the sclera itself covered with rudimentary chorioiil from the and marginal is tissue (see Fig. tropic eyes. small papillie are generally redder than large ones.18 is very dark. the so-called pigment ring. the tissue ring. whether gas or electric. line. is oped considerably more 4. or scleral ring. while a According to Elschnig. one \jhite. which is not always constant. The white ring may be due to two different anatomical conditions: chorioid it may be either a true connective tissue ring.in in emmethe text and Fig. If this ring lies close to the papilla a connective tissue ring cannot be seen. has an influence on its color. for the zone of pigment in infants than in adults. which so-called is connect ivi' sometimes termed erroneously the chorioidal ring.

in which tiie spreading out of the tihei-s of the optic Tlu' coloi. they suddenly become indistinct at this point bright. as a rule of the same lu^itrlit.of such a nerve takes place wholly on a level with the retina. The margins of the papilla are slightly elevated and surround a funuelshaped excavation. The presence recognized ophthalnioscopically from the fact that the reddish color changes either suddenly or gradually to a whitish. in they cling to the wall of the sclerotico-chorioidal canal and leave center. tlio p<ii)illu rises iihovo it the is level of the surrouiuling retina only in exceptional cases. a larger or smaller funuelshaped or cupshaped cavity below the of this cup is level of the surrounding tissue. in the latter they suddenly bend like hooks. The excavation fill is due to the fact that the the fibers of the optic nerve do not completely out the hole in the chorioid. 15)- The transition from the tissue proper of the papilla to the excavation is may be either gradual or abrupt. but a colored zone always lies it and the adjacent retina (see Fig. to be perceived from the behavior of the vessels in the former case they pass without visible bending into the white place. — Small Excavation in the Temporal Part of the Papilln. and the white spot. as they swell out like a fountain. it It may occupy only a very small part of the papilla. is nearly absent (see Fig. which indicates the excavation in the other type. . or between may be so large as to reduce the normally colored portion to a narrow circle or crescent. dark color at the edije and sinndate there a verv dark . or become more or less invisible. or to white. thei-e is scarcely any difference in color between the nasal and temporal portions. While they may and a])pear as be seen clearly and distinctly from the margin of the })apilla to that of the excavation. If they plunge downward very abruptly they have a markedly of the excavation. Two types need to be differentiated: («) The flat papilla. Fir:. This X in the text and Fig. (b) The excavated papilla.19 idea. The size of the excavation varies a great deal. papilla is almost uniformly reddish. E. D in the text). indistinct bands at the bottom of the excavation.

as it were. end on. The excavation maj' be in mm deep. as it j)lunges downward. Hence it is that the light streak. If both 3 D lens must be interthe observer and the patient are ennnetroj)ic. Upright Image.20 swelling. As 1 mm ^3D (see page 10). that they do not Fig. like the beak of a bird (see Fig. a — . perhaps also because at this place the vessel is seen. visible everywhere else. M). but bend to one side. — Schematic Drawing of the Fundus. tlie floor of tlie excavation are sometimes is or to follow different courses. F. plunge straight down from the margin of the excavation. is absent at the place where the vessel bends (see page 105 and later). The reason why seen either not at the vessels in all. in this case the apparent end of the 1 vessel is apt to be pointed. a change must be made the lenses of the ophthalmoscope in order to bring its into focus the vessels at bottom when using the direct method.

The bottom portion alone tone. Sometimes reaches to the Fio. rarely into the lower. . but the branches that emerge from the papilla. Ever// abrupt cxcnva- that extends to the margin. Parallactic displacements The position of the excavation is usually central. of the papUla of the excavation is U to hf conaulereJ pathological.21 posed to enable the former to see tlieiii clearly. these are caused by the meshes of the lamina cribrosa. hut there tiori it slopes away gradually. If the vessel divides within the optic nerve it not the trunk.— fSchematic.) This figure is retinal vessels intended to show in what way the great variety in the courses of the comes to take place. G. is temporal margin. is not uniformly white: usually the central of this color. also are visible when the depth is sufficient. it frequently extends it into the temporal portion. while the peripheral parts have a reddish gray Dark points may also be seen in the white itself.

and so on. one fourteenth of the diameter of the vessel. in this atlas — for the subdivisions are not sym- Sometimes the vessel divides within the optic nerve. No ana'^tomoses arc which in turn spring two smaller ones. and arc by no means so distinct as those on the arteries. from arteries and veins. Branches of the same kind of vessel never cross. but the until they are invisible. a fact that can often be utilized to deter- mine the nature of a vessel which cannot be seen distinctly. sending a downward. branches can be differentiated as such. which are usually larger than the corresponding nasal branches. and are sharper in their outline. and then two principal branches coming out of the papilla perhaps one of these has already divided so that apparently 3 vessels emerge In at least the great majority of cases the 4 chief from the papilla. although wherever two vessels cross one is always an artery and the other a vein.narrower. It is a matter of importance to know this fact. The macula come. because it may hapj)en in certain diseases that the vessels atrophy we see not the trunk. and lacii of temporal and nasal arteries draw a very schematic pictui'C. everj' man. but no regidarity can be observed Arteries and veins frequently as to wjiich of the two is the upper and which the lower. as a rule. cross. 5. . so that only from their entire number can the absence- of a vessel be disclosed. I have not seen a single one in the manv thousands of eyes that have examineil ophthalmoscopically for the purpose of ri'pi-dduction metrical. The wall of the vessel is perfectly trans- perceptible only under pathological conditions. but they do not seem to have been successful as yet. which is not regular. ami vein divide. from the superior and inferior temporal arteries and veins. follow more direct courses.. rather than from that of the vessel parent and is itself. are of only about two thirds the size. the superior and the inferior temporal and nasal Each of these divide again into two branches. but individual to Attempts have been made to utilize this condition. to Tlic artcrv two branclus. the breadth of which is about one quarter the diameter of the vessel. They are bright red and have distinct reflexes. The Vessels. streaks which are considerabh. This light reflex probably comes from the surface of the blood column. but they frequently arise directly from the common trunk. the superior and inferior artery and antl veins seen only in extremely rare cases — at I least. and in ) manv cases from the system of ciliary vessels (see under Cilioretinal vessels more slender than tlie veins. . according to BertiUon's system for the purpose vessels of the of identification. The veins are wine red and have light arteries are The The arteries and veins can l)e distinguished apart easily. But such a regular subdivision as this schematic drawing is actually present tlusi' sul)(li\i(k' into branch upward and anotlier vein of tlie papilla.

In an abrupt excavation of the optic nerve the pulsation can be seen best in the veins that bend over the margin of the cup at an acute angle. and wounds. at the instant when the intraocular tension falls. The contraction and paleness of the vein begins just before the beat of the radial pulse. or ciliary arteries. the venous pulse a phenomenon that can he observed It is in most men. by the it is activity of the right ventricle and auricle of the heart another is that caused by the continuous transmission of the pulse wave from the arteries through the capillaries into the pressure. vessels These are branches of the central which pass into the vascular systo in tem of the chorioid without touching the retina. as a rule. is If the venous pulse slight not visible otherwise. while. i. pulsation can be seen in the arteries under normal conditions. which compresses the soft-walled veins. One theory is that it a negative pulse caused . as newly formed vessels. Vascular anomalies which 1. pathological conditions. or seem to end in a point on the papilla. and appears there most distinctly in the veins that are flattened to the greatest degree. synchronouslj' with the cessation of the arterial wave of blood. are to be looked upon as normal are: The Cilioretinal Vessels. Zinii's in the region of the connective tissue ring. The Opticociliary Vessels.Venous No Pulse. Greater pressure may excite a lively arterial pulse. and then. form of hooks at the periphery of the papilla. Inuncdiately after the radial pulse comes the dilatation and the center. choked disk. A a spontaneous arterial pulse must always be considered pathological. or in those that bend at a right angle and form a dark knee at the place where they bend. the veins refill. filling of the vessel from the periphery toward The way in which the venous pulse is is brought about is explained in a variety of ways. lie to be seen only. According to Elschnig can be seen in everj' seventh eye. though in the principal it is ordinarily not very marked. veins. and thence have derived the arteries. A third theory is that an elevation of the intraocular pressure created by the arterial wave of blood. such as glaucoma. Only one venous trunk pulsates.e. . and pass into the retina like the other They it is arise from the vascular plexus. it can be produced by making pressure on the eyeball. is on the contrary. extends from the center toward the periphery. They are almost thej' all exceptional to meet with a vein. They are very rarely be found in normal eyes but are more common. the possibility of such an occurrence intraocular. name of cilioretinal vessels. venous trunks which on the papilla. but rarely passes over the margin of the papilla. 2. in the These emerge vessels.. is being provided for by the comparatively high extravascular.

. for it is found only in eyes adapted dark and is transformed in the light into "visual white. brown or black brown.\t to the ehorioid with the layer of pigment epithelium. If this layer is very dense nothing can be seen of the ehorioid. stippled fundus. is brought about by the fact tiiat the layer of pigment epithelium contains so nuich and such dense pigment that the ehorioid beneath observer." Pigment (see Fig. The tone of color is red. and we have the uniform. and we have a tesselated fundus. Sfippki] Fundus (Fig. if the layer of pigment epithelium is not very dense the chorioidal pigment can be seen. Three Types of the Normal Fundus. The Uniform. according to tho quantity of pigment. THE FUNDUS OCULI. although its Fig. 1). The uniform aj)pearance of this type of fundus 1. The way is of less imexert any influence. chorioidal pigment is also wanting the fundus is albinotic. In the ehorioid the pigment is situated chiefly between the vessels. and in the intervascular spaces of the ehorioid. We ment in distinguish.B. according to the quantity and distribution of the pig- these two membranes. it is completely hidden from the eye of the red. — Distribution of Pigment. greatly influenced l)v tlie color and density the color of the hlood vessels in the ehorioid visual purple can in no portance. If the name might to the lead one to suppose it could. The retina (above) terminates ne. is The color of the fundus of the pipiient . H. H) is found (a) {}>) in the layer of pigment epithelium of the retina.

forming a yellowish white background. 3). or converge towai-d tlie periphery (vortex veins). Cases are often met lium witli which do not belong exclusivelv to any one type. have no liglit streaks. but present the characteristics of two or more. can often be seen. In Retinal Vessels varies according myopia they are markedly drawn out. have light streaks. The Tessclated Fundus it is (Fig. of pigment in the fundus is usually in keeping with that in the hair and skin of the individual. The vessels appear as is sels bright bands on a dark background. consequently' coloring mat- possible to see througli the almost transparent retina and to perceive the markings of the chorioid. They can be distinguished from the retinal vessels by the absence of the light reflex. The Albinotic Fundus (Fig. 2). are deep. or a bright is background (Type III). form many anastomoses. The Course of the eye. little In this t>'pe the layer of pigment epithelium contains so the markings of the chorioid are again visible. But this membrane also has no pigment. less In this type the layer of pigiiicnt epithelium contains ter. divide irregidarly. converge toward the papilla. so that we speak of a blonde. This tortuosity is due to the growth of the eyeball being too little as compared with . while of the to the refraction in hypermetropia a marked tortuosity. even The retinal vessels can easily be distinguished in the albinotic eye. and consequently the sclera retina is seen to shine through the and cliorioid. TJie reddish chorioidal vesare seen to form numerous anastomoses. The abundance brunette fundus. are superficial. The laver of pigment epithein may be thick enough to hide the markings of the chorioid it is some places. so that even in an albinotic fundus the chorioidal vessels are visible in the macula. while in others thinner and allows the chorioidal vessels to appear on a dark (Type II). by noting the following characteristics Retinal Vessels appear to be round. their abundant anas- tomoses. in The pigmentation not usually usually densest about the papilla and the region of the macula.: 25 2. although they can be seen in the less pig- mented places in the periphery. form no anastomoses. divide dichotomously. Chorioidal Vessels appear to be flat. 3. upon which the chorioidal vessels appear as dark bands. and of a from the chorioidal. especially of the veins. have no uniform direction. and the pigment of the chorioid massed in the interv^ascular spaces between them. and their deeper position. or no pigment.

running parallel to margin at the distance of It about one papillary diauRter. P. like spots. surrounded P. D. broad and 1 This ring surrounds the part of the macula lutea which contains no nerve fibers. oftenest in at the posterior pole. . It mav' be recognized from the behavior of the blood vessels. A bright curved line can its many cases on the nasal side of the papilla. has the form of an oval. 3- Macula. but lacking in without reaching lies it. with must not be confounded with the Weiss-Otto shadow ring. sometimes crescentic. but this theory cannot be correct. This is known as was thought by its discoverer to indicate a detachment of the vitreous. brilliant reflex ring 21/. Weiss' reflex ring. young people by a D. as when a than when contracted. D. the vortex veins. which can be recognized easily to be reflexes by the fact that tiiey change their forms and positions with movements of the head and mirror. in con- sequence of the elevation of the surface of the retina by the vessels. they are it less distinct when the pupil is dilated is The explanation like of these reflexes that. 73)It The Chorioidal Vessels have been to the described already. which is met in high myopia and indicates the margin of a sclerectasia. In exceptional cases. or a +- ghiss used in looking at the is fundus of an emmetropic eye. pulse see page 107) juid this The normal tlic conditions of circulation (for pressure absence of any moriiid symptoms diflferentiate from other forms of tortuosity. high. as shown in Fig. the macula lutea in the narrow sense. and to be pathognomonic of myopia. usually myopia. pears rather dark. caused by the reflection of the light from the sides of the foveal funnel. concave grooves are formed which act be seen in concave mirrors. they lie lie in the periphery. and 21/> P. The area papillary blood vessels. so it will suffice to say that they gather the blood into large veins. which are caused by morbid conditions of the vessels and intlannnations. Its center apis 5 papillary diameters (P. in This.) broad. are particularly distinct when the vision -f"l) is They focussed on the deepest is part of the vitreous. The macula deserves a special description. 2). the so-called staphyloma verum (see Fig. according to the way in which the lifht is thrown and the mirror held. as the line is met with in ennneti'opia and hypermetropia. as they appear chiefly along the vessels and in the region of They appear in the forms of bandlike. The Retinal Reflexes form a very marked j)henomenon. In the center of this ring the so-called reflex of the fovea can usually be seen in children. it which surround and direct their points at thus surrounded by. it This portion of contains a yel- the fundus oculi has been termed the macula lutea because low coloring matter. which. especially in young persons. and so it appears sometimes roiird. It about ll/o diameters from and a little above the papilla. number of four or more. yet the area that contains this yellow coloring matter is considerably larger than the place that this is designated ophthalmoscopically by name. high. D. or islandthe macula (see Fig.!2() the design of thu vessels. some- times wedgeshaped.

2. 1. Normal Fundus of the Tesselated Type. I Normal Fundus of the Uniform.PLATE Fig. Stippled Type Fig. with Numerous Reflexes from the Retina .

has sharply de- fined margins. temporal portion is is brighter than its nasal. The it j)igment epithelium so dense is that no details of the chorioid heneath can he {)erceived. The bright spots in the vicinity of the macula can be recognized to be reflections from the fact that they change whenever the mirror is moved. The pigment jiarticularly concentrated about the pa])illa and in the region of the macula. see page 25). the Al- brighter. The dark. are the veins. A small branch of the artery and of the vein approaches the macula. we sec the folliiwiiig details: The papilla vertically oval. reits garding in turn its form. with Numerous Reflexes from the Retina In contrast to Fig. 2. though their subdivision is not quite regular. This picture shows that there is little pigment in the retina. without distinct light streaks. its margins. narrower ones. we say that the tesselated fundus is characterized is b^' bright chorioidal vessels on a dark back- ground. 1 the markings of the chorioid can be seen over the greater part of this fundus. a bright zone about the papilla. diirerenccs of level. larger vessels. The pigment so there is of both the retina and the chorioid lacking in its vicinity. The dark. yet the division above and below of both the arteries and the veins into 2 principal branches can be seen. It is normal in color. Stippled Type (Sec page 2-i) If vrc study the papilla in tlie way repeatedly mentioned in the text. with distinct light streaks. is and its vessels. Fig. very clearly marked connective tissue and ])igment rings. are the arteries. lies islandlikc places are its vessels ( formed by the pigment of the chorioid that between intervascular spaces.Fig. but plenty in the chorioid. As the vessels of the chorioid are brighter than the pigment lying in their vicinity. is This is because the pigment layer of the retina it very thin and allows the tissue beneath to show through. and its a shallow excavation in center. Normal Fundus of the Uniform. 1. the temporal poris tion distinctly brighter than the nasal. and has a distinct connective tissue Its ring. The macula and fovea can be seen quite distinctly because the reflections at their margins and along the courses of the vessels are verj"^ great. 28 . The papilla vertical^ oval. but no pigment ring. Normal Fundus of the Tesselated Type.

.Tab. Fig. 2. Fig. 1.

.

II Albinotic Fundus . 3.PLATE Fig.

in most cases this takes place the periphery. The vessels of the latter can be very plainly seen to unite into larger trunks. the pale surroundings. is and those of the chorioid. 8- 30 . but only in consequence of its the effect of contrast with fined. The is confluence of the vessels of the chorioid in the neighborhood of the papilla in rather unusual. margins are sharply de- excavation vei-y shallow. even when the albinism . Albinotic Fundus This picture shows a complete absence of pigment in both the retina and chorioid.5. 3. see page A partially albinotic fundus shown in Fig. The arteries and veins cannot be distinguished from each other. The is papilla its is bright red. For the differentiation between the vessels of the retina 2. the vortex veins. the retinal vessels are normal.Fig. in pigment is is the region of the macula is likewise a distinct accumulation of pigment at this The complete absence of not common more often there place. in the region of the equator. perfect otherwise.

Tab. 3. . Fig. a.

.

Conus and Staphyloma Differential Diagnosis of the White Rings and Crescents to be Found in the Immediate Vicinity of the Optic Nerve .

.

4. I exclude here inflammatory affections. 3.^ The 1. will In order to differentiate the individual conditions we group tlirin first with regard to their positions as respects the papilla. either anatomically or etiologically. with some attention and knowledge to the factors that enter into the problem. and to draw from them of thi? optic norvc affords a important conclusions with regard to the diagnosis. this classification and hemorrhage. chorioid. and to be grouped by them under the term "large papilla. one of them in may appear alone an otherwise normal fundus.: . great fullness of the vessels. 3. Medullated nerve all fibers. Peripapillary atrophy of the Conus inferior. and ]>osition. Staphyloma posticum. which usually a yellowish. Conus temporalis. the which the crescent and the circle are the principal types absence of signs of inflammation. and emphasi/. a?dema.e the point that Conditions are grouped serves a purely practical purpose. which may lead those who are inexperienced into error. sueh as cololioniii of the sheath of the optic nerve. the position.t. it is not difficult to differentiate the individual conditions. principal conditions to be taken into account are 2." but. in the innnediate neighborhood of the ]>apilla . certain forms of ooloboma of the chorioid. Halo. as they are seen in ' A number of other conditions mi. color. they have a certain resemblance to one another in form. but have only common. or bluish white. 2. of 4. 33 . but they have been omitted because of their rarity. such as optic neuritis. on the other iiand. features common is to all these contlitions are: the color. some features in together which have nothing to do with one another. and. 5. Conus and Staphyloma Differential Diagnosis of the White Rings and Crescents to be Found The head in the Immediate Vicinity of the Optic Nerve number of anoniiilics of tliis nature which are apt to be thought parts of the papilla by those who arc not expert. 6. abnormal developnient of the glia tissue and of connective tissue. The 1. the form.ht be inchnloJ.

may be found comparatively often at the same time with the conus temporalis. inferior will be described a little later. This is due to the fact that the retina. at least partially. niedullatcd ner\e fibers. which. rt'inombering that everything is reversed in the inverted image. .ij)li\l()ma posticnni. 1.34 the upright imagu. may combine with those that have been mentioned and overthrow the in artificial fabric thus the staphyloma posticum may appear company with hemorrhages. the staphyloma posticum annulare. it may surround the papilla. or with diseases of the macula. the peripapillary atrophy. (b) Belme it the conus inferior. in excep- tional cases. or. the st. or the peripapiUary atrophy. at first glance to be rather risky. but then the temporal portion The color may vary The crescent may may be white only at the mar- gin of the optic nerve and may have a reddish yellow. to the nasal side in the its inverted image. cover the optic nerve at can be seen only indistinctly through these membranes. Toward Tiiis the retina is usually presents a more or less broad edge of pigment. the connnon form of conus. it on the opposite side of the nerve. Such an arrangement as because other conditions this may seem . («) On its temporal side lie. but then side. at this place The Conus lies (Figs. (f/) Above it medullatcd nerve fibers. the so- supertraction. or a reddish brown be of such a color. so that it and it may be even the sclera. retinitis albuminurica may present an appearance which seems at first sight similar to that of these conditions. chorioid. this place. can be distinguished from the staphyloma by the fact that it exhibits no visible vessels of the chorioid. The conus though rarely. tone toward the retina. or the entire crescent A called change in the medial margin of the sheath of the optic nerve. But I consider this differit ential diagnosis to be of sufficient importance to introduce in spite of these objections. toward the temporal also. lie The conus may. which rarely attains at the diameter of the papilla. 4 and 5) is a uniformly yellowish white crescent widest part the breadth of half it that ordinarily to the temporal side of the nerve. the peripapillary atroi)iiv. (c) Surroitiiiliiig it the halo. is extends. In rare cases the broadest. when typical. Certain deviations from this typical form are met with. or may lie tlie conns temporalis.

it does not pass through the sclera thus thus \.35 The conus may be the result of vai-ious anatomical conriitions. in order to understand its Normally forms a funnel with is smaller opening forward. thus / •\. The upper drawing. is due to tlie fact that the outer layers of the retina and of the pigment epithelium. I. On the opposite side the optic nerve is covered by the retina and chorioid. on the left side in the drawing. —Head of the Optic Nerve in Myopia.gives the ophthalmoseopie appearance presented by the condition the oblique course of the delineated in the lower. The congenital conus all. or conus. Consequently the sclera is seen through the retiua and chorioid on the temporal side. the aperture in it. the sclera through which the optic nerve this canal passes. so that the sclera This form differs only quantitatively from the scleral ring. \. ill-defined crescent. ways. A. and that temporal B. in readily be understood that this it is form of conus occurs other than myopic eyes. are rudi- mentary. and it This is the result of the stretching that It takes in va- place in the posterior part of the globe in myopia. partly also by the sclera. side. not necessarily strongly marked on the Acquired conus. after Fiichx. or not formed at shows through. indistinct. which gives the picture of a white crescent. which dif- fer again as thev are congenital or accjuired. rious is may be caused necessary to recall the normal configuration of the Pig. hut when a conus present the temporal side has been ground off so as to form an oblique canal vn\\\ parallel . When compared with Fig. but optic nerve is striking. It can over the area that is white. so that this portion of it is seen D / \ only through these membranes and appears as an which is called the supertraction crescent. as well as the chorioid. sclerotic canal.

Aside from the rare cases of congenital conus that may be met with in hypermetropia and enmietropia. is is As it does not simply stop at the margin its interstitial of the optic nerve. we must consider the Conus as a Sign of Myopia. but intimately united with tissue. the distraction crescent. is fil)ers apt to be torn between the retina and the stroma over The to latter then perishes. The pathological is condition lies in this form is a uniform stretching of the segment of the eyeball that behind the equator. also called a dint ruction cnscint. 'i"he There are two forms of myopia. It is otherwise with congenital - myopia. tlius \. Many writers call the one named the retraction crescent. Others make no distinction between conus and staphyloma. so the white color at this place fibers it. the elastic lamina of the chorioid. or detachment of the retina. uniform. without . caused by the color of the sclera plus that of the glia With regard Fig.^ is produc(>d in way The retina antl the chorioid do not yield if|ualiy in the stretching at the posterior pole. This ordinarily exhibits pathothe form just de- logically a circumscribed stretching. which is apt to be complicated by here The nomenclature of these crescents is not uniform. It is associated with a greater or loss degree of outward bulging of the sclera. a better term than "congenital myojiia. its usually stojjs when the body ceases to effect is exhausted in the formation of the conus which has been mentioned. I in the origin of the so-called supertraction crescent. and vice versa. and as grow. but one which is much more marked than that in scribed. in its production. ophthalpresents perhaps. the life. indifferent to whether it obliterated vessels or not. like near work. We may go even a step farther. which rarely exceeds in 6 or 7 D. Another form of conus. This is and near work is an etiologic factor the benign form of myopia. . the text and the accompanying explanation. and gives ophthalmoscopically the impression of a staphyloma This is the malignant form. see. and is complicated only exceptional cases by diseases of the macula. former develops during school espe- cially in children in the higher grades.: 36 walls.The expression "myopia to which the predisposition is congenital" is. As the tissue covering the optic nerve is transparent the wall of the canal at this place can be seen. confined to the region of the posterior pole. and by conus the moscopic appearance caused by that condition. understanding by the latter only ^ a true bulging outward of the posterior pole of the eyeball. acquired and the congenital. not giving way in like manner as the retina. posticiun. calkd the retraction the following crescent. and of comparatively slight degree." for one that develops siwntaneously any externa] provocation. in particular. must be taken into account. and forms the ophtiiahnoscopic picture of a conus. As this process of stretching it very slow. a fold of the optic nerve of the chorioid. • • •\.

" and the staphyloma is an indication of congenital myopia. and a commencing detachment of the vitreous.37 changes degree. forms so prominent an salis: ii) symptoms that wc may The presence of sclerotic r-es. explanation. but by shadows that are produced by irregular outward bulgings at the posterior in some places. 54. On the farther side of the margin of the staphyloma are to be seen chorioidal vessels that have undergone similar alterations. Aside from an outward bulging and a thinning of the sclera. but this interpreta- . Still. in the macula and (litacliiiient of the retina. by the unequal advance of the atrophy. to the condition presented by the conus. which on the temporal side of the papilla. but the term the crescent. pole. while in others ever. some of which are totally obliterated. usually larger than a conus. Sometimes the time of the completitni still of the atrophy varies in different parts of the staphyloma. The Staphyloma (l""igs. 73). but these are still covered by the veil of pigment. particularly of addition to the its vessels. sclerosed chorioidal vessels arc found either in the crescent. which was once thought to indicate a collection of fluid between the retina and the chorioid.icls of is say. indicative of staphi/lonui. is the above-mentioned outward bulging of the posterior pole of the eye to he understood when we speak of a staplivloma. The sharply defined crescent can be seen to contain chorioidal vessels. ari' t i-ansitioiial forms. these breaks are not caused Such a shadow may also appear around the posterior pole. the same pathological conditions are to be found as in acquired conus. which is is also applied to the ophthalmoscojiically visible evidence of its presence. but In contrast broadest part is on the temporal side of the latter. while some contain blood. the breadth of the crescent and the presence of other changes nmst in be taken into account Fig. reple. their absence of conus. brilliant. giving rise to a terraced appearance (Fig. The name staplivloma deserves Properly speaking. with the black pigment of the intervascular spaces distinctly visible between them. or nndtiA fine. but it is usually to be seen only on its nasal side. or "school myopia. cum grano the chorioid. all This staphyloma until it is may hasten through in the stages of atrophy of tlie chorioid total. and is frequently double. which is absent over the area occupied by the crescent. howit cannot (Fig. !)ut in general it may be accepted as a fact the conus is an indication of acquired myopia. except that atrophy of the chorioid. and to attain a high Between tliese two extremes tliat. even then its is situated in most cases Less often it surrounds the nerve. especiaU// the vicinity of the crescent. 6. 70). making the diagnosis. or in its immediate vicinity. 70-73) appears ophthahnoscopically as a white crescent. tlie 6 shows a staphyloma posticum in early stage of its develoj)- mcnt. 2. as shown Fig. so that breaks appear through which the pigment of the chorioid can it be perceived within In many cases. flex curved line is frequently to be seen on the nasal side of the ])apilla.

the directed toward the case the ectasia does not lie exactly at the posterior pole but rather below it hence the papilla is not situated exactly in its nasal wall. The white is staphyloma. this . the papilla is situated in its nasal wall and profile is consequently seen in half its with shortened. L. horizontal axis forecrescent. the staphyloma. and the foreshortening is consequently of its oblique axis. is directed toward the center of the ectasia.38 Fig. J. The ectasia affects exactly the posterior pole of the eye. it. Fig. Fig. and it ap- . K. In this case the ectasia lies to the nasal side of the posterior pole so that the papilla occupies the bottom of its cavity. Consequently we look directly at pears to be of its natural. The staphyloma is circular. but in its upper and nasal. Schematic sketch is to show how the papilhi In caused to appear out of drawinsr in hifrh myopia. center of the ectasia. The white crescent. round form.

is. The conus inferior differs plainly its from the staphyloma posticum and the form of the papilla. partly to the effect of contrast with bright surroundings. result Peri- and parapapillary atrophy of the chorioid. and made by the ectasia on all sides of the papilla. and in is usually associated with a change in the form of the papilla.£9 tion is not correct. but at shown by Dimmer. most and seems to be smaller than normal. not round. the papilla upper inner wall of cavity. but clings to the if is downward and outward. the latter broadest if in the horizontal meridian the papilla appears to be vertically oval the broadest part inclines somewhat is meridian. and the foreshortening takes place in an oblique axis (Fig. the principal axis of the papilla this is oblique. is The dividing line between the conus inferior and the papilla frequently it is not as distinct as in Fig. i. the staphyloma circular (see Fig. or reil(ii>h and indistinct redness and indistinctness are due partly its to the pulling. but oval. Conus is inferior (Fig. 8. this relation between is the form of the staphyloma and that of the papilla readily understood. the of arterio- . position. K). drawn out As a rule it (see is page 105). in half profile. as sucli a lino sometimes appears (see in other conditions of the refraction page 26). conus myopicus not only in in the vessels of the chorioid 4. the latter the ectasia its lies strictly on the nasal side of the former. 65). If the ectasia is situated on the nasal side of the posterior pole the papilla tiie occupies the floor of as the hollow is hollow and consequently we look directly at is it. The . lies l)elow the nerve. though to a greater degree in some than in others. The papilla lies to the nasal side of the posterior pole of the eye. strictly on the temporal side of the papilla. in consequence of the ectasia of the posterior pole. eitlii'r The papilla itself may appear when a staphyloma is present. downward from this The explanation of it that in the majority of cases we do not look directly at the papilla. L).. but also in the absence of scleroses in the and Peripapillary Atrophy of the Chorioid (Fig. short diameter vertical to the broadest part of the staphyloma is . J). The with if retinal vessels are very slender and is form of the papilla its quite interesting. the more this is stretched the more the papilla moves toward the inner side of the cavity formed by the ectasia if the ectasia is as has been . obliquely or transversely oval. the color of the fundus Astigmatism is uniform in its upper part and almost alhinotic m its lower. In almost all cases. 3. Like the latter. which cases. and the foreshortening then affects only the horizontal axis (Fig.e. Anomalies in the nature of the excavation and in the subdivision of the vessels are often present. The normal. 8)is This a special form of conus which to be regarded as a rudimentary it coloboma of the chorioid. and amblyopia are usually associated with this form of conus. chiefly in As the atrophy of the chorioid occurs is the places where the stretching greatest.

and from the tissue of the 6. the and glaucoma. The is color varies according to the density and number of the fibers. 7)5. The halo glaucomatosus can readily is be diagnosed as such when the course of the retinal vessels noticed. in It is met witli in old people. in most of these cases the sheaths tliscontinue at the lamina cribrosa and little reappear a retina. On the other hand. Tlie halo cle a more or less broad. or reddish tinge of color. posticum. MeduUated Nerve Fibers fibers (Fig. is quite siiiiilur in appciirancc to staphylomn. . 9). the halo glaucomatosus. suffices A to single vessel that bends sharply over the margin of the pajjilla positive make the diagnosis of glaucoma and to reveal the true nature of the ring. an indistinct margin. radiating striation can be cesses into the normal retina. but send flamelike procontrast. tiie It is char- acterized l)y white cords formed by sck'rotic vessels of the chorioid. lii<e Its margins arc and it sends out narrow projections. feelers. yellowish-gray cir- which is inmiediately adjacent to the ])apilla. while is the sharply nut lined form of a crescent indistinct. as the fibers spread out in the papilla or the These fibers usually adhere to the papilla and lie above or below it for the most part. generally absent. in consequence of the color of hap])ens very rarely that the medullary sheaths of the orbital segment of the optic nerve continue without interi-u])tion into the intraocular portion. sometimes bluish white. complete or partial. but they spread out in in exceptional cases the fibers retain their slieaths as the retina and hide all the tissues beneath them with a mantle that is sometimes yellowish white. The Halo is (Fig. 14). The of the optic nerve are accustomed to lose their medullary sheaths before they pass through the lamina cribrosa and consequent!}' be- come transparent. Some- times the ring has a more yellowish. yet no sclerotic vessels can usually be seen within it ophthalmoscopically. farther on. 65- It is onl}' in exceptional cases that this sclerosis takes the form of a staphyloma (Fig. a reddish yellow when the density of the fibers the subjacent portion of the fundus. The corre- sponds to an atrophy of the chorioid and of the pigment epithelium. The uncovered portion of the papilla then appears particularly dark red from the effect of These fibers never have a sharp margin. pa})illa by its color. It slight. which may be caused by the simultaneous presence of an exutlate between the chorioid and the retina.40 sclerosis. very often covering the corresponding margins. from the scleral ring by the indistinctness of its margins. Usually a distinct. into its neiglibor- hood. the halo senilis can l)e readily distinguisjicd from staphyloma by the absence of visible vessels of the chorioid. and fades witli away halo into its surroundings halo senilis. as shown in Fig. it is It a ])ure white when the fibers of the entire layer are is opaque.

the absence of logical changes. staphyloma.41 perceived in the white area. Rabbits (Fig. 86) always have medullatcd nerve horses have them very often. . serve to distinguish them from exudates and from patches of degeneration (see page 128). as well as its innnediate connection with the papilla. the indistinct border. while the superficial ones This behavior of the vessels of the retina. pletely covered The deep vessels of the retina fibers. may be com- may jut out more or by these nieduUated nerve less sliarply from the wliite mass (see page 102). fibers in their retinae. such as all other patho- hemorrhage and oedema. and peripapillary atrophy. the color and the striation are sufficient to differentiate medullatcd nerve fibers from conus.

.

Conus Temporalis. 5. Supertraction "School" Myopia . 4.PLATE Fig. III Conus Temporalis in Fig.

Zinti's arterial come from the central artery of the retina. 4. hut at certain places the vessels of the chorioid may be seen through the pigment layer. 44 . Conus Temporalis (See page 33) Next crescent edge. Supertraction (See page 34) in "School" Myopia At the temporal margin of the head of the optic nerve is a crescent somewhat different in form and color from that shown in Fig. 4. 5. tlie temporal margin of the disc of tlie optic nerve is a narrow white wiiicii is separated from the rest of the fuiuhis hy a sharply defined is The For papilla plus the crescent surrounded by a strongly pigmented the anatomical explanation of such a crescent. and is a cilioretinal artery (see page 23). in consequence of which its outline is indistinct (see page 34). ring. The fundus is uniformly pigmented. tlie line An artery arises from wliich does not of delimitation between the papilla and the conus. Conus Temporalis. on the whole. of the optic nerve shows a distinct excavation in its The head portion. but from plexus. The excavation is very deep and the meshes of the lamina cribrosa are to be seen distinctly in its floor. The sclera is drawn over the nasal margin of the papilla. see page 34. temporal Fig.Fig.

4. Fig. 5. . Fig.Tab. 3.

.

Crescentic Sclerosis of the Chorioid Arteriosclerosis Due to .PLATE Fig. 6. 7. IV in Commencing Staphyloma Posticum Myopia "Congenital" Fig.

4 (compare \vith the schematic drawing in Fig. but also the change the close to the head of the optic nerve. The neighboring vessels of the chorioid appear to be diseased. and so allows the markings of the chorioid to be seen distinctly. chorioid is The presence only suggested. see Fig. Commencing Staphyloma Posticum Myopia (St'c in "Congenital" page is iJT) The term staphj'loma posticum bulging of the eyeball at chorioid induced by of the retina. The epithelium not very thick elsewhere in the fundus (tesselated fun- dus. 54). 6. an indication tiiat "congenital" myopia has a progressive character. 65. Crescentic Sclerosis of the Chorioid Arteriosclerosis (See page 39) Due to A picture can be produced by arteriosclerosis that closely resembles the preceding.Fig. pigment also should disappear in the course of the disease the crescent would become pure white and resemble the conus in Fig. This picture was taken from the eye of a I)oy 10 years old. 7. The papilla itself and the retinal vessels are normal. of pigment between the sclerotic vessels of the This picture was taken from the eye of a man 68 years whose refraction was emmetropic. old. has undergone total atrophy over the area of a parapapil- lary crescent. who of had 12 D myopia (see page 37). Fig. 2). which it is made to include not only tlie outward in its posterior pole. vessels advances such pictures may be created as As the sclerosis of tlie those shown in Fig. so that the If this chorioidal pigment wliich between them conies out very plainly. 46 . The visible vessels of the chorioid are lies almost wholly obliterated.

Fig. 4. Fig. .Tab. 6. 7.

.

Conus Inferior. 9.PLATE V Fig. 8. Partial Albinism Fig. Medullated Nerve Fibers .

e. These of the fibers form an absolutely harmless congenital 'inomaly. . 8. usually in immediate connection with the papilla. almost invariably they follow the courses of the vessels of the retina. is The rest fundus normal. in it.'39).g. part the vessels of the retina the latter appear to be narrowed places. while the rest of unifoi-mlv colored. For the cJiffcrential diagnosis from other conretinitis. nection with the papilla and extend out from redder than usual from the effect of contrast. particularly from albuminuric see page 128. Medullated Nerve Fibers (Sec pages -K) and 128) immediate con- Medullated nerve fibers ordinarily lie. but. certain They form a mass that is striated. Fig. overlie in in beneath them.Fig. cases these patches may be of considerable extent. Partial (See page 39) Albinism The into .. 9. is brilliant and that In rare often ends in delicate. or rather subjacent. ever lies The papilla seems to be The fibers conceal whatAs they white. •18 . crescent. Conus Inferior. Dark vicinity seen scattered the conus (see jxirtion pa^e The of the fundus it is in tiie of the conus is distinctly albinotic. demarcation between the it The about in line of pajjilla and the conus spots can l)e is as sharply defined as is in this case. ditions. the more intense color of the pigment epithelium generally to be found in the vicinity of the papilla. as in this case. they Although they are be found separate may from it in exceptional cases. separate fibers which look like white hairs.i papilla has a reinarkahlj transversely oval form which circle is completed not always by the adjacent.

Tab. Fig. 8. ') . 5. Fig.

.

Atrophy Atrophy of the Optic Nerve .

.

It must be understood from the start that alone does not tiie tlie ophthalmoscopic condiin tion suffice to establish the diagnosis many cases. A many. perhaps. Conditions of the Vessels. Jaeger. between nutritional and simple atrophy. but is that simultaneous determination of the vision and of the visual field imperatively demanded. When 51 a large physiological excavation . Some remarks concerning in the so-called atrophic excavation niay be forms of order before passing to the consideration of the individual atrophy. and tiiat its Following the lead of t'. 2. The atrophy. but yet the medium types can be it. i- Color and Transparency. ami in in The alterations so in color the significant. latter then become plainly visible. guished by by no means as easy as distin- might be supposed from the chart. while the observer falls looking at the papilla. because the nerve latter of which fibers alone disappear in atrophy. yet Elschnig many autliors speak of an atrophic when he maintains that no such picture can be seen either with the ophthalmoscope or with the microscope. 3. the is sometimes increased. so that the apex of the cone of light Slight changes in the color of the onh' on the margin of the papilla. Margins. I readily may. the changes the optic margins are apt to be the most nerve will be grouped first from these points of view. for example. appear too schematic to is admit that in individual cases the differential diagnosis. guide to the differential diagnosis of the various forms of atrophy It can be found on the next page. Whiteness of the Optic Nerve. Conditions of Level. and this forms its justification. excavation. use of indirect illumination is often of value in cases of is commencing For is this purpose the mirror turned a little to one side. leaving the stroma and connective tissue. is right occurrence cannot be understood pathologically.ATROPHY The changes in tlie optic nerve are to he considered mainly from 4 points of view for the purpose of diagnosis: 1.

52 DIFFERENTIAL DIAGNOSIS OF THE VARIOUS FORMS OF ATROPHY .

disappear and give place to a white tone after it has once been observed. Total Atrophy 1. — — the color has no signification in the differential diag- In the . such as meningitis. and to investigate the general condition. caused by cerebral disease. or the reverse may take place. Primary atrophy is the same as that which has frequently been termed gray atrophy. Tabetic atrophy begins. As the other ophthalmoscopic details. the anteater. This uill not prove difficult to those zc-ho ore accus- tomed to consider the papilla always from the ^ points of view. unless we are able to find other points in the eye that are of diagnostic assistance. Etiologically. Level: normal. Margins Vessels : - normal. Simple atrophy presents the foHowing characteristics: Color: white to gray white. We see the same picture in the in both The true diagnosis will depend therefore on the findings general and neurological examination. It rarely 1 A number of animals have perfectly white papillse. in the form of a neuritis. account its color. Simple Atrophy^ (Figs. but we may almost say again unfortunately nosis. is Hence. first place. fortunately. or it may be due to injuries What etiological conclusions or compressions. the color alone changed. the it seldom third. can be drawn from such a condition? UnThe atrophy may be of a true neurogenous origin. : normal. and hydrocephalus. Tabes rule. the porcupine. instead of the white of the papilla. but this does not belong to the typical picture. very many. 2 When a eonus or a staphyloma is annexed to the atrophic papilla it may be differentiated from the latter by the fact that it presents a peculiar. in the second. met with comparatively has been seen many times in other forms in the gray tone of color is . to take into A. it is secondary. for example. ruther yellowish white. miiryins. the armadillo. surpasses everything else in importance. smaller in the later stages. tabes is the first disease to be thought of. 10 and 11). level and vessels show no deviation from the normal in it may typical cases. yet syphilitic diseases of parts that are situated more centrally. to notice all This is why it is so important other ocular symptoms. then come Syphilis of the optic nerve usually appears general paralysis and syphilis. and the hedsrehog-. so as to resemble The retinal vessels may become nutritional atrophy. gumma of the chiasm. may cause a simple atrophy secondarily. or of a neuritic atrophy.53 toms that are present. level. . when cases. we have to include under the caption of simple atrophy clinical pictures which are etiologically very different. and vessels. the margins. as a very early in the disease and may be for years its only symptom. the rhinoceros. when it is primary.

indi- optic nerve. Differential diagnosis. Out of the tliat I Iiave seen who were hhiulcd by this disease. Tabetic atroj)hy almost always affects both eyes and leads to blindness. atrophi/ of the optic nerve. as in fracture of the 10) by direct or base of the skull. because of his ataxia. especially when the pupil also dilated. important. . indicative of syphilis. this is becomes pale. or a paresis of a portion of the oculomotorius. syphilis. like Sometimes syphilis appears quite as tabes in its toms. Among them may be men- tioned as particularly optic nerve (Fig. compression in the optic canal. or concentric losses. while a facial paresis. is A central scotoma with total atrophy atrojihy of nniltiple sclerosis. or bilateral ptosis. as in oxyccphalus. A of the abducens. points rather indicative of symptoms of hemi- toward general paralysis.^ None of the other causes are very frequent. Tabes frequently causes an ocular triad. antl present the same appearance as other blind persons. and then the differential diagnosis may be very Wassermann\'i reaction is often positive in tabes. i. the more so Atrophy of only one ophthalmoplegia. tabes. when the pupil does not is react to either light or convergence.54 appears at the same time with the ataxia of large number of patients I it tlie lower liiiihs. generallv syphilitic rather cate that the disease than tabetic. probably present. and pressure of the arteriosclerotic carotid upon the intracranial portion of the Pathologically. though with remissions. especially in connection with plegia.. and the papilla subsequently ^ In the rare cases of tabes with central scotoma there at the same time. these blind persons.e. when the immobility of the pupil general paralysis or syphilis tabes. interruption of the conductivity of the indirect injuries. simple atrophy of the fibers of the optic nerve takes place without material proliferation of connective tissue. slowlv growing tumors at the base of the nerve. reflex imvtohflit// of the pupils. it may be rather suddenly. paresis of the ocular muscles. is whom likewise the of sight for orientation absent. is internal bilateral paresis of the oculomotor nerve. When we find a reflex immobility of the pupil is associated with a simple atrophy of the optic nerve. while in multiple sclerosis it is the vision that is lost first. can reeollect only a very few who had a high degree of ataxia. is is absolute. Another dilTereuce between tabes with central scotoma and multiple sclerosis is that in the former the papillae are pale at a time when the vision is still good. with partial The field of vision in tabes usually shows sectorlike. is Althoiigii to be feared that a tabetic who closes his eyes will lose his balance in and sense fall. both the vessels is a concentric contraction not present in multiple sclerosis. go about quite well. an accompanying hemianopsia. the reactions of the pupil this is may be preserved in paresis is while almost never the case in tabes. total accompanying sympdifficult. Meiosis occurs only in On the other hand. the case one of tabes. skull. hydrops of the third ventricle.

together with the condition of the retinal vessels. sometimes varicose. the line of separation can usually be recognized plainly from the differ- ence in color between the two. is As to be expected in arteriosclerosis. with normal margins and level usually. though not always. which are called coronuhe and are described on page 127. the level vessels alone are altered. small patches of degeneration are found in the macula. as a rule. 16. not rarely found company with like arteriosclerotic vessels in the chorioid. In many of these cases the first things that can be seen by accurate observation are irregularities of caliber. normal." and are considered to be characteristic of arteriosclerosis of these vessels. vision is usually totall}. and the atrophy caused by chronic disturbances of nutrition are differentiated by this fact from the Atrophy Due The 45. greater quantity than it can under normal conditions. but this due only to the absence of contrast. but tlie many cases they seem to be obscured by a surrounding ring. the veins are usually In'oad.55 and the capillaries are preserved. whicli changed optical conditions induced by tiie atrophy of the nerve make it it possible for the lamina cribrosa to reflect the liglit that falls in upon more sharply and 2. We should observe carefully where the papilla stops and the halo begins. thickenings of the walls. condition develops which . arteries are threadlike. but later appear to be contracted. 44 and described on page 150. The 3. color in this form of atrophy tlie is The a gray white rather than a pure in white. The visual disturb- ances are comparatively trivial in these cases. It is this form of atrophy in it is usually met with in old people. the optic white. no longer visible in some places. which often surround a staphyloma (see page 39). It is probably due to the fibers. Glaucomatous Atrophy (Fig. of this The appearance described. proves the diagnosis. and obliterations of the smaller vessels. with the exception of an arteriosclerosis that is often moderate. margins of the papilla are sharply defined. For this reason the margins of the papilla appear somewhat indisis tinct in many cases. so-called halo. Nutritional Atrophy.lost in these cases. 14). Hence the white or gray discoloration tiiis of the papilla cannot be caused in way. while the arteries are engorged only at first. frequently pulsate. such as will be described later under "The Changes in the Vessels of the Retina. is After the acute symptoms have passed illustrated away a The disk is by Fig. is Othertiie wise the margins in this form are sharply defined. and is to Occlusion of the Arteries is picture of acute occlusion of an artery shown in Figs. The vessels are rarely quite normal. may be extremely like that of the atrophy just Only the absolutely negative evidence of a neurological and internal examination. .

but this bend does not take place moscopic picture is Fig. disk the vessels at the mart^iii of thr tlic As can be of tlie phiiiily seen in Fig. margin of the papilla.v.ains ponched out on Fig. be. When we look from in front upon a vessel that dips down at this place it will not be visible as it courses along this pouch.56 This form is sli. course of the vi'ssels up to the marniii optic is perfectly ^ J . The exeavation laterall. 14.J Fin. The optic nerve is its nasal side. — Deep Physiological Excavation.i.ir])l_v (lillVrinl iaicil jiapill. A vessel coursing over the margin of the excavation may bend in a manner similar to that followed by those in a glaucomatous excavation. at the 15. N. — (ilaueomatiuis Exeuvation.v sharply at tlie margin of the papilhi. from all otliers by the behavior of 14. In contrast to the preceding drawing the excavation does not begin at the margin of the papilla. but will apparently come to an end at the margin of the papilla. M. The optic nei"ve itself is reduced by atroph. These pathological conditions correspond to what is seen ophthalmoscopically in Fig. The corresponding oishthal- . but normal tissue lies between the margins of the disk and of the excavation.

The surface of the papilla usually rises a little above the level of its sur- The margins remain roundings.and sucni to disappear in tlic cavity. The floor of the ])apilla usually lies The fact that it is abrupt and extends make a is 1 mm behind to the margin distinguishes the glaucomatous from the physiological excavation. the so-called opticociliary vessels. the difference of level between the excavated papilla and surrnumi- ings can be determined. majority of cases the vessels are also accompanied by white stripes. or formed into loops. 4. only by a change of focus of a concave glass —that — in the direct method by the interposition they can be seen in the floor of the excavation. and by the invisibility of the apertures in the lamina cribrosa. From the difference in focus and page 9) between the vessels on the margin of the from the parallactic displacement (see pajjilla and those on its its floor. The vessels less are always changed degree. sometimes junctions between the retinal and chorioidal vessels. many In old glaucomatous eyes we find obliterations of the vessels throughout new formation of large vessels at the margin of the papilla. but It they are hidden by the proliferation of connective tissue. markings of the lamina cribrosa are very plainly in older ones fresh cases. 12 and 13). which are frequently twisted like corkscrews. and inflammations that occur in . (see page 104) are also observed more often than usual. 13). or choked disk. the veins are tortuous. Neuritic atrophy is clearly distinguishable from all of the other forms by the indistinctness of the margins of the papilla. but that the excavation and the behavior of the vessels suffice for the diagnosis. or in the excavation. engorged to a greater or difference is arteries in are smaller than This In the particularly marked old choked disk (see Fig. to a fairly high degree when the atrophy is due to choked disk. while the . under the influence of an in antiglaucomatous treatment the excavation undergoes involution cases. but this color changes pretty soon into a pure white. are not rarely seen on the papilla opticociliary vessels . total. the level of the retina. no excavation and none of the details of the lamina cribrosa are to be seen. indistinct and striated. the papilla is at first white gray with striated or obscure margins. may be said here that the color of the optic nerve need not be abnormal in the commencement of a glaucoma.57 normal. but it is tlifre thuy Ix'nd suddenlj. Newly formed vessels. Moreover. These phenomena become the more marked the longer the inflannnation In cases that run a rapid course a neuritic has lasted. may therefore some- times appear very like a simple atrophy. are also to entire areas of the retina. normal. distinct WhenThe ever a vessel is seen to hook over the margin of the papilla Usually the excavation visible in is the diagnosis of glaucoma justified. In the atrophy that follows neuritis. as well as a be seen (see page 10-i). Ncuritic Atrophy (Figs.

normal . all Etiologically.58 old age arc apt to have severer seciiula' tlian tliosc that affect younger persons. The differences between the atropines caused by inflammation and by choked disk equalize themselves in the course of time.a What it is particularly marked is the great diminution of the size of the . there in many cases an entrance of pigment into the atrophic retina. Temporal. Atrophy of the Optic Nerve and vessels are perfectly is The margins. which is white the former. on the other hand. especially in young people.ui the nasal. so that it is sometimes impossible to make a differential diagnosis between these two forms. which usujillv are sharply defined tinct in nutritional atrophy. tlic indistinctness of the margins of the papilla. inflammation was not confined to the papilla. especially in the periphery (see page 174). The 5. 12. On tlu' other hand. indisin retinitic. which causes an uncertain grayness about the optic nerve. 51) it is is to be considered only as one symptom its of a clinical picture. The is condition of the retina. but. are to be ascribed to a jiroliferation of the glia tissue. as is usual for the glance of the observer to fall first on the pa])illa when he making an ophthalmoscopic examination. es])ecially when due to occlusion of the it central artery. and by the color. it is evident that great care must be exercised in making the diagnosis. or level. retinal vessels. If the diagnosis cannot be made positively from the ophthalmoscopic . can cause an optic of those factors have to be taken into account which neuritis. so-called retrobulbar neuritis can never cause a neuritic atrophy.show no changes in their walls in this respect may resemble nutritional ati-ophy. B. which ordinarily . discolorations and partial vascular changes of particularly Tf the high degree are iiccustomed to appear as is sefpiehe. Pathologically. as shown in Fig. The Atrophji of the Papilla 'ni lietinitis Pigmentosa (Fig. characteristics may be mentioned here. as the temporal portion of the disk is normally nuch brighter th. but may be differentiatid from this by the condition of in the margins. is conmionlj. though the stripes along the vessels may be caused in part by changes in the tissue of the walls of the latter. Retinitic atrophy has a certain resemblance to the neuritic form in that the margins of the papilla are indistinct yellowish gray. rather than a pure white. yellowish in the latter. but involved its surroundings. situated in this portion As large physiological excavations may simulate a temporal paleness under certain circumstances. as well as the stripes that accompany the vessels. and. Partial. however. : its color. the only variation from the normal to be seen the paleness of the temporal side of the papilla. decisive as regards the diagnosis.

59 picture. the field of vision is to be investigated. The ^ disease actually begins in the ganglion cells of the retina. with the outer portions of the normal. mas. and an immobility is almost never seen (see page 54<). It follows both eyes in from the nature of the cause that the disease regularlv aff'ects Case 1. particularly in diabetes. bisulfilix phide of carbon. this is Pathologically to be considered as a fibers. . which at first only f(jr green and red. or through the influence of toxines some time after its subsidence. Chr-onic iutoxicdtions. quinine. other signs. is Preeminent among these a question is poisoning with alco- hol and still whether tobacco alone can produce such an Then follow the toxic effects of methyl alcohol. later for white also. secondary atropiiy of the papillomacular bundle of optic nerve which passes over the temporal margin of the papilla and supplies the macula hence the central scotoma. as well as of autodisturbance caused by this condition intoxications. The stereoscopic method of Haitz for the determination of a central scotoma is very simple and valuable (see page 79). lead. tolnicco. field If a central scotoma is ' is found. and may precede b^' years all Nystagmus when is the eyes are turned as far as possible to one side or the other frequently present as an accompanying of the pupil 3. is Multiple sclerosis. while in Cases 2 and 3 only one eye may be affected. The inflammatori/ diseases of the posterior ethmoidal cells and of the sphenoidal sinus may bring about a similar picture through an extension of the inrtammation to the optic nerve. etiology is of very great importance. . The visual present in about half of the cases of multiple sclerosis. paresis of the ocular muscles are less common. symptom. a positive diagnosis of partial atrophy may be made. 2. eifect. of the The determination temporal paleness 1. as the may It be caused by very different diseases. atoxyl. and arsenic.

.

Fig. Simple White Atrophy of the Optic Nerve Simple Gray Atrophy of the Optic Nerve . 11. 10.PLATE VI Fig.

Hence we have to think first of tabes. The dark spots in in the chorioid showing through the This patient had tabes. The history stated that a stick had penetrated the orbit of the patient at a time when he was stooping. 62 . so that. The diagnosis therefore was atrophy after Therefore everything about normal except its color. that margins are its vessels distinct. Fig. and that it is are normal.e the vessels. the retina more strongly pigare visible along the region of the macula. that its level is the same as that of the retina. 10. but in this case the result of the neurological examination was negative. except for its level and vessels of some sHppling which indicates the apertures in the lamina cribrosa. by applying our schedule. 11. and that the eye had been made blind innncdiately. Simple White Atrophy of the Optic Nerve (Sec page 5:3) When wc study systematically the color. distinct reflex stri. Simple Gray Atrophy of the Optic Nerve (See page 53) As in the preceding picture the color of the disk . vessels retina (tesselated fundus).Fig. and the vessels smaller. marn^ins. is The fundus mented in is of the tesselated type. In the later course of the disease the gray became brighter. its the jiapilla wc see that color is white. is the only deviation and from normal the fundus are caused by the pigment the margins. level are normal. we are led to the diagnosis of simple atrophy. interru])ti()n of conductivity (see page 54).

Fig.11. 10. .Tab. 6. Fi.

.

Neuritic Atrophy Atrophy of the Optic Nerve after Choked Disk Fig. 12. VII Atrophy after Inflammation of the Optic Nerve. 13.PLATE Fig. .

papilla is white. it can be seen from the ring surrounding the disk how far the swelling extends into the retina. The otiier eye of the patient. Atrophy after Inflammation of the Optic Nerve. 13. Pigment has migrated into the retina. Neuritic Atrophy (See page 57) The stripes. the vessels are bordered hy white The The indistinctness of the papilla its is due to a proliferation of glia which fills does not cease exactly at margin and the cavity of the excavation. as . Fig. the margins of the papilla are indistinct. is shown by the mounting of the vessels at its margin the vessels themselves show the disproportion in size between the arteries and veins characteristic of choked disk. The papilla is distinctly elevated. Atrophy of the Optic Nerve after Choked Disk (See page 57) As in the preceding case. who died of gliosarcoma of the cerebellum soon after the completion of tho picture is shown in Fig. The vision was much impaired in this case. 25. and has produced the gray halo about the jiapilla. stripes along the vessels are caused partly by a proliferation of glia. 64 .Fig. which has been rendered atrophic by the inflammation. its margins indistinct. 12. partly hy changes in their walls (see page 58). The cause of the optic neuritis in this case was syphilis. which had been acquired 3 years before. the excavation and tiu' mark- ings of the lamina crihrosa are erased.

7- Fig. 13. Fig. . 12.Tab.

.

. 15.PLATE Fig. VIII Glaucomatous Excavation and Atrophy Large Physiological Excavation Fig. 14.

M in the text. The holes in the lamina cribrosa can be seen very distinctly in the floor of the excavation. N. contraction of the visual and there was a considerable concentric particularly marked on the nasal side. encircled by a sliarply defined scleral its ring. 66 .Fig. as in the last picture. vision in this case The had rest of the fundus uniform and The fallen to one sixth of the normal. Fig. The vessels of the retina do not stoj) at the margin of the excavation. is much deeper tlian that of the retina. and caused by the over- the in. 15. but can be plainly traced. to wiiich added a yellowish gray ring wliich blends with surroundIts level ings in a less distinct margin (iialo glaucomatosus. Comj)are with this the pathological is drawing. page 56. Fig. We conclude from this fact that the sides of the excavation are not precipitous. Glaucomatous Excavation and Atrophy (Seu payc 55) The tone color of the pjipilla is gray in the center. like the sides of a cup. but they the disk. although their direction is changed. sti])pled.iigins. is what with hanging of way is in which the mirror Tlu' papilla is held. see page 40). Large Physiological Excavation (See page 50) In contrast with the preceding picture we see here a narrow zone of normal tissue between the margins of the papilla and of the excavation. margins and vessels of the papilla are normal. The retinal vessels are not mate- rially altered. 14. Compare with this the pathological drawing. The color. but that thoy slope gradually. field. especially tlir on the nasal is side. with a gray green shadow which varies some- in tlie ninrgiiial i)ortions. and from this and disappear exactly at the margin of we conclude that the excavation is abrupt and extends break off to the margin of the nerve. Fig.

Fie. Fig. 15. 8. . 14.Tab.

.

Paleness of the Optic Nerve . IX Atrophy of the Optic Nerve after Occlusion of the Central Artery Fig. 16. Partial.PLATE Fig. or Temporal. 17.

The discovery of the temporal paleness led to the neurological examination that disclosed the presence of this serious disease. 17. ciliary vessels by Fig. This patient had at the same time a central scotoma. 68 .of the Optic Nerve The margins. 16. The vision of this eye was totally lost. Partial. In the macula points. in color of the vessels and level of the papilla are normal. but its temporal half exhibits an abnormal paleness that far surpasses the ordinary difference temporal from the nasal portion. As a general rule the arteries are completely refill empty of blood from the » for a few days after the occlusion. tlireatilike. a coronula of little bright tlie characteristic of an occlusion of artery that took place some previous time (see page 127). its arteries In the vicinity of of the fundus as tlie optic nerve is to he seen again un uneven coloriiif^ the consequence of an immigration of pigment into the atrophic retina. and then gradually way of Zinn's arterial plexus (see page 168). which he complained. which at is is to be seen. its margins arc fairly distinct. Paleness (See page 58) .Fig. examination revealed that he was suffering from nmltiple of vision caused by the central scotoma was the The neurological The loss only subjective symptom of sclerosis. framed in pigment. Atrophy of the Optic Nerve after Occlusion of the Central Artery (Sue JKlgL' 55) is The are papilla is white. veins are of apj)roxiinately normal size. or Temporal. its level its the same as that of the retina.

.Tab. in Fiar. 9. 17. hi".

.

Optic Neuritis. Retrobulbar Neuritis. and Choked Disk .Abnormal Redness of the Papilla.

.

The bearing of all these possibilities nmst be recog- nized and correctly estimated before a hypenfmia can be decided to be the iorcrunner of an optic neuritis. is and even with a slight prominence of the papilla. It must also be remembered that a hyper<-emia of the papilla may be induced by a pro- longed examination with the ophthalmoscope. 71 . which is present all cases of optic neuritis and is always absent in pseudoneuritis. may be added. and in such circulatory disturbances as are caused by heart disease. in empj'emata of the accessory sinuses. and consequently has been termed pseudoneuritis. the impairment But pseudoneuritis can be positively differentiated from optic almost by the absence of the oedema about the pajiilla. just the same as paleness. Optic Neuritis. as these conditions of refraction sometimes impair the vision. there is a hyperajmia which appears as an accompani/ing symptom of morbid processes. demands a special consideration. a particular form that is extremely apt to give rise to mistakes. or of disturbances in the field The presence of vision. looks rodder in young than in old persons. but Hypermetropia. with of the margins of the engorgement and tortuosity of the anil vessels. or hypermetropic astigmatisni. because the color of the papilla varies phi/aiologicaUi/ within rather wide limits and. is dependent on a number of secondary factors.. or by tumors of the mediastinum. although the optic nerve itself is not diseased. especially in iritis and iridocyclitis. which may be termed physiological. neuritis in is commonly present viz. yet the condition not pathological. and Choked Disk Itself I. of hemorrhages. with which in it is necessary to be acquainted order to estimate correctly the influence they exert. Pseudoneuritis may appear with an obscuration disk. Finally. it appears to be redder when the light used it saturated with red rays. Retrobulbar Neuritis. in these cases. but these symptoms are absent many cases. another symptom of true optic neuritis of the vision.Abnormal Redness of the Papilla. moreover. ana. as for example that from a kerosene lamp. or of a choked disk. congenital. or by severe accommodative efforts in hypermetropes and presbyopes. in injuries of the eyeball. as in inflammations of the anterior and posterior segments of the eye. Aside from these causes. in a A papilla always appears redder blonde than is in a brunette fundus . Redness of the Papilla by is without any other symptom a condition that must be considered with ex- treme care. renders in the diagnosis of optic neuritis certain.

or pure gray ring. to its — If we follow our j)lan color. broadening and tortuosity of the veins. small pox. not a disease per se. and. inflannnation in Among the local causes may be named suppurative skull. wliich surrounds the entrance of the optic nerve tissue that lies beneath and within it. Tlie redness is caused by a congestion of the smallest vessels signification has already been considered. should we neglect to make a general examination of tlie organism when an o])tic neuritis is present. The commonest cause of an optic neuritis is syphilis. diphtheria. pneumonia. because hides the markings . and did not seek out the cause of the cough. The case would be parallel if we were satisfied witli the diagnosis cough. ritis is is to Optic neube looked upon as a symptom Heme it in our diit/f in liiix cvfry cattc of optic neuritis to asccrtiiin the fun- produced it. Obscurations of I^ittlc its 2. 2. usually of the treneral organism. 3. margins. the next quency is in fre- alhuiiiiiiiiriii. peripapillary (edema. the various forms of basilar meningitis due to acquired or hereditary syphilis or tuberculosis. They are tuberculosis. abscesses in the brain. scarlet fever. 4. and vessels. Optic Neuritis from optic neuritis is is The difTcrentiiition of pseudoneuritis of so tlic much the greater ini])ort<ince because the hitter an indication of presence of some other <rrave disease. Little change in the arteries. first of all. clmuliness of the tissue of the papilla. It is to it be seen most plainly in an albinotic. and myelitis. which sometimes are provided with accompanying streaks. The peripapillary oedema forms and obscures the a reddish gray. malaria. or in the accessory sinuses (see page 78). Redness and cloudiness of the papilla. or a tessclatcd fundus. the orbit. due to local causes is apt to be confined to Diagnosis. damental disease which The causes are manifold and may be either general or local.II. level. 1 or 2 papillary diameters broad. and the obscuration brought about by a marked oedema which permeates both the head of the optic nerve and the adjacent retina. margins. Note and of its to 1. but of another serious disease. while that commonly one side. to examine the urine and to test for Wasscrmann's reaction. in the car. or no elevation. diabetes. is should be noted that the inflammation excited by general disease bilateral. Note to its The is margins. such as typhoid fever. the acute infectious diseases. epidemic cerebros])inal meningitis. and anomalies in the It form of the such as oxycephalus. and study each papilla with regard we find the principal symptoms of optic neuritis to be: 1. All other causes are of secondary importance.

CHOKED DISK.73 DIFFERENTIAL DIAGNOSIS BETWEEN OPTIC NEURITIS. AND PSEUDONEURITIS .

or in the region of the macula. acute and may. as the result of a larger or smaller. In pseudoneuritis the either normal. while the same symptom in produced is pseudoneuritis by a so copious (le\elopment of the su|)])ortinif tissue. A better delimitation of tlie papilla reappears with the subsidence of the dies inflammatory symptoms. or impaired is by the associated refractive error.is distinctly is Vi<^. The onset of optic neuritis in a become fully developed few days. remain as mementos of the . to a less deirree. pei-ci'ivi'd (Uil\' and the unviiled parts is very striking.a. A distinct elevation of the jxipillti is not apt to be presint be tilled optic neuritis. is 22. but field. eaust'd by this (I'dema is so <rreat that both exhibit is (litHcultv of distin^'uisliinir tliim a])art so the same color. Patches of degeneration and hemorrhages are often found near the papilla. when the inflammatory lesion of the j)aj)illa. may affect only a portion for example. yet less often than in connection with choked disk.74 of the iii. its nasal half. The inaririns of the optic nerve are obscured is iiy a peripapillary ledenia in in of)tic iiciiriiix. so that the contrast hitween the veiled The same it conditions. in that case.(l cliorioiil lis it tliut ill iirv t'lscwliure in visil Ic. this laid on the why much stress is demonstration of irdema the diannosis of the forme)'. at least at first. the (rdi'Mia pai-ticularly j. neuritis as they are naturally absent The vision and the condition of the visual Held are also of great value. delicati' veil can he from the fact that a seems to be spread over certain parts of the retinal vessels. Sonutinies are shown in Fif^s. The demonstration of such hemorrhages oj)tic is likewise of the greatest importance to the diagnosis of in ])seudoneuritis. wliich case unusually favorable conditions are present. no anomaly ever found in the visual The Course of Optic Neuritis. and only the changiits vicinity. tion of this fact The determinais of im])ortance in in the diiferentiation from choked disk.\rki. is In optic neuritis the vision apt to be very nuich impaired from the first. and thence may gradually spread to the whole. relative or absolute scotoma. The is veins alone are really channed. but any excavation that exists may uj) by the oedematous tissue. Xote to 4. and then the enormous that the position of the papilla can be recognized oidy from the confluence of the vessels. they are broadened and tortuous. while in choked disk vision is it is apt to be normal.rcat ami the fundus is very rich ni details. the hypera'mia away. anil of vicinity. 18 20. Note to in a. It is not always . in the vessels and a smoky cloudiness over the papilla and through which the former appears of a dull red yellow. or may be it may take a chronic form. In which a marked disproportion the fullness of the two kinds of vessels in brought about by the sinuiltaneous diminution the size of the arteries. while the arteries usually retain a normal caliber. The vessels are not infrequently jirovided with white stripes. its In many cases the redness and cloudiness of the papill.

in the A complete white discoloration of the in nerve naturally appears results. hut. with deposits of pigment. scarcely the papilla finally shows a whitish. are fre- the j)eripherv. which may be In the cases either total or partial. course of time the cases in which a greater functional trouble This has already been described on page 57. in spite of the uniformity in the essential points. even become quite normal again. and the question arises whether these differences the etiology. or a tuberculous origin. 21). arranged . ^ ery marked obscuration of the margins of the nerve is suggestive of syphilis. which is more marked always the on the nasal than on the temporal side.retinitis specifica) can often be recogfen- nized from the presence of a large oedema. The retinal vessels also show sclerotic like changes in many cases. Old or fresh patcher quently to be seen in in the chorioid. while those due to local lesions are usually unilateral. in I'onNeciiience of which hemorrhages. peachlike hue. we have to notice whether patches can be found the chorioid that suggest by their appearance a syphilitic. characteristic may not be utilized in ascertaining In regard to this differences. Further points may be drawn from the following: 1. central opacity of the still vitreous which contributes to render the picture more oliscure. What Etiological Conclusions can be Drawn from the Ophthalmoscopic Picture of an Optic Neuritis? It can be seen in Figs. 18~22 that. cannot be emphasized too strongly that we must not be content with the diagnosis "optic neuritis" in our ophthalmoscopic examination.75 presence of a morbia process or less (Fif^. but nmst carefully investigate the other in parts of the eye search of [loints indicative of the etiology of the disease If of the optic nerve. which this discoloration is suggested there is still a change in the tone of color of the j)apilla from the soft. poreelainlike red. The functions return to a ^-eater degree witli the involution of the intianiniatory field in the cases in whicli the vision and the visual in symptoms. it must be noted that there are no quite but that certain points may be utilized in one way or It another. where the atrophy ()j)tic is more distinct. atropine discoloration. to a hard. which have been described on page 133. Sf/phUitic optic rifuritis (neuro. Although this statement does not hold good It absolutely. yet it is a guide to a certain extent. which extends into the retina the distance of 2 papillary diameters and mav be so dense as to cover the it optic nerve and the retina with so uniform a layer as to render to tell impossible where the former stops and the latter begins. we should fail to find the hemorrhages and white spots in characteristic of the albuminuric form. the various pictures present considerable differences. has already been mentiontd that the forms of optic neuritis caused by general diseases are for the most part bilateral. delicate. Usually there In such a case the situation of the papilla can be determined onlv from the confluence of the vessels. is a diffuse.

the primary inflammation is very rare and the transmitted very common. in the latter the form trated in Fig. in addition to other cerebral symptoms. Only too often we do not find these distinctive features. In the former case we see illus- the large oedema described above (perineuritis). to he seen (Fig. it is rarely that the diagnosis of syphilitic optic neuritis will fail to be should also be mentioned that a specific basilar meningitis may pass from the meninges to the optic nerve and create the picture of an optic In these cases we have to expect. which give rise to diplopia. Albuminuric and diabetic optic neuritis can often he distinguished by Usually the retina so the early appearance of hemorrhages and patches of degeneration in the retina (Fig. cially on one side. the reverse is true in tuberculosis. is not as fatal. and sion of every other cause that may produce an optic neuritis and the existence 19. as in Fig. made. because most of the patients die at an early period. Although the primary inflammation of the optic nerve is the rule in xi/philis. It is of tuberculous lesions elsewhere in the body. the optic nerve.76 the spokes of a wheel. 20). pareses of the ocular muscles. but see such a picture as that shown in Fig. 18 (interstitial neuritis). 19). When an atrophy is found as the consequence of a "meningitic" optic neuritis. as this 3. mydriasis. unless tubercles are time in the chorioid or the optic nerve. The extent of the oedema depends in part on from what place in the optic It nerve the inflammation starts.5 to 30% of all cases. 35)- I" many cases an albuminuric . or in young people. 58). visible As a rule it is not possible to recognize tuberculous optic neuritis as at the such from the ophthalmoscopic picture. The prognosis a tubercle is is doubtful. and the extension from the meninges forms the exception. As Wassermann's It test must be made in every case. I'hthoff says that it is the most frequent ocular symptom in tuberculous meningitis. or from its may originate either from the sheath of interstitial tissue. 18. the inflammation is observed only in exceptional cases. thouijh mucli less often present than in alhumiiHiric ntinitis. In spite of this an atrophy as the result of an optic neuritis due to a tuberculous meningitis is seen very seldom. it is bad as regards litV in the cases in which situated in the optic nerve (see Fig. paresis of the accommodation. usually the atrophy alone 2. An optic neuritis due to hereditary syphilis is rarely seen. and iiimiohility of the pupil to light. If the picture presents tins form we may he quite certain tiiat the case is one of syphilis. and is then usually associated with meningitis. the cause of the latter was probably a syphilitic meningitis. retires is much the more aflFected that the neuritis to the background (see Fig. espeneuritis. as it occurs in from 2. at the time of the As this disease occupies is the attention acute symptoms. niid white spots are not uncommon. met with almost is to be diagnosed by the exclualways in children.

point in the dift'crenti. is Arteriosclerotic optic neuritis distinct characterized by a rather sluggish the vessels of arteriosclerotic changes in To make ture is the diagnosis of arteriosclerotic optic neuritis from such a picis permissible only when the morbid process observed from the start. Picture showing. of Ophthalmology. if the vessels are changed only a is and there is little redema. numerous lymphocytes. the inflammatory has frequenth' been observed that after the opening of an ab- symptoms augment considerably . 5. — Neuritis Optica. \ % " -^ Fig. a complication added to the otitis in the form of a meningitis.il diagnosis of diabetic optic neuritis is is that the accompanying central scotoma course and more or the retina (Fig. 21)less often extremely minute. from Tioemer's "Textbook The interspaces between the bundles of fibers are dilated. are permeated with and it .the pathology of the inflamed optic nerve. optic neuritis usually exhibits only engorgement little. In exceptional may also present the appearance of The otogenous . the oedema increases very rapidly and such a picture may ensue as that shown in Fig. an abscess. O." and the fibers themselves. It 22. has been ascertained that this picttire represents the acme of the otherwise the same picture could be brought about by an optic neuritis disease due to some other cause which was undergoing involution. cases an arteriosclerotic optic neuritis a choked disk. A 4. while it is not necessary that the functions be materially altered. as well as the interstitial tissue. or a sinus thrombosis.77 optic neuritis may liavo throutjliout the appearance of a cliokcd disk (see page 76). and hyperemia But.

8. sometimes a marked choked In many cases of abscess of the orbit a thrombosis of the retinal vessels produced. In acute poisoning with methyl alcohol more marked symptoms are disk. and especially renders scotoma tant . The prognosis is opened at the proper time. it is No other forms of optic neuritis have anv distinctive characteristics. i. ' (Neuritis fasciculi papillomacularis Toxic neuritis. the origin of which is a destruction of the ganglion cells of the retina. The disease usually begins suddenly with a visual disturbance which permits the patient to orientate. .78 scess. III.) in An ophthalmoscopic atlas.e. marked contrast to the otogeis that the disturbance of vision. but they appear to be gray or "dark. to be seen. yet it usually good when the diseased must be made with some reservain Sometimes these forms of optic neuritis resemble which is their course disk. The forms in of optic neuritis that are caused by abscesses in the orbit a and empficmxis of the accessory sinuses show nous large. Retrobulbar condition is neuritis. The diagnosis is possil. because picture of this is not presented the no change produced is in the appearance of the head of the optic nerve in 95% of the cases of the disease in question. or ascendincr in this disease. at least the chronic cases. but when it is met with usually in company with the characteristic roundish patciies in the ciiorioid illustrated in Fig. cavities are tion. hut tliis it has no iinfavorahli> influeiice on the prof^nosis. which can be recognized by the deep black color of the colunms of blood and the absence of the pressure pulse (see page 107). in necessarv to relv whollv on the results of the general examination order to determine their etiology. 40. but precludes the distinct perception of fixed objects. for example. it impossible for him to read. The ' The neuritis may be considered to be secondary." while ral vision. as has been proved by the pathological examination of persons poisoned with methyl alcohol during the past year in Berlin.le in all chronic cases only through the demonstration of certain subjective symptoms. some a choked Individual cases present an atroph}' of the head of the optic nerve is that demonstrable on tiie third day. a central scotoma which often very mav be (juite considerable at a time whiii scai-crly anytiiiiiir wrong can be seen on the optic nerve. Axial Optic Neuritis . the demonstration of a central is fairh' eas3^ The examination with it is colors is particularly impor- the color of small green and red objects cannot be recognized centrally. is tlie axial. usually runs a l)enign course. perceived at once by periphe- as soon as the patient looks to one side of the object. If he is then examined with the perimeter. some resembling a partial atrophy. Under proper treatment 6. Si/mpatJtctic optic neuritis it is is a very rare phenomenon. 7. and in the re- maining in 5^ the only change a little hypera'mia and engorgement. or with Haitz" charts. described below..

as in par- or temporal. that a form that can scarcelv albuminuric neuritis may assume be differentiated from a clioked disk sclerotic optic neuritis also has the witli patches of degeneration. —The charts devised by Haitz are extremely useful for the de- monstration of a central scotoma. beginning is is decisive The size of the central scotoma not absolutely dependent on the extent of the area of distribution of the paiiillomacular bundle. and diabetes. When may prognosis it is possible to induce an alcoholic it is to abstain from liquor in cases of his vision return. The behavior of the vessels. intoxications. hut the dein the monstration of a central scotoma for green and red as regards the diagnosis. the so-called albuminuric choked disk. lead poisoning. it is poisoning with sulphuretted hydrogen and carbonic oxide: ratlier better in diabetes. At first there is usually nothing to be seen with the ophthalmoscope. is still uncertain whether it is caused purely by engorgement. is The not so good. The two halves of the chart are superimposed by into a stereoscopic picture tlie action of prisms so that they fuse and appear as This enables the healthv eve is to maintain an accurate fixation while the other tested for the presence of a central scotoma. should be remembered that a number of diseases. one. it ma}^ be smaller than this.59). Arterio- appearance of a choked disk in many cases. especially in diseases cf the accessory sinuses. This question is of comparatively little importance to tlie clinical picture of at least one form. diseases of the accessory sinuses. atrophy of the optic nerve. to be seen (see page The same tial. diseases are to be taken into account etiologically. It and multiple sclerosis (see page . the veins . or by inflammation. it is not until the process passes over into atrophy is that a paleness of the temporal side of the optic nerve •58). IV. The most essential points of difference between an optic neuritis and a choked disk consist in 1. as in diabetes. on account of in exceptional cases its great etiological Importance. The prognosis depends on the cause and the stage of the disease. In clioked disk there tlie is a verv consid- erable difference in the fullness of veins and of the arteries. or of axial optic neuritis. though not absolutely bad. Choked Disk There origin is as yet no universally accepted theory as to the nature of the it of choked disk.: 79 perception of yellow and of blue is also lost in the later stag's. Note. otherwise his optic nerves will become permanently atrophic. or it may be considerablj' larger when the adjacent parts of the optic nerve are involved. with graduated lines These charts consist of symmetrical halves in and can be used an ordinarv stereoscope. It deserves to be particularly mentioned. such as empyema of the accessory sinuses. may induce the picture of either true optic neuritis.

-iuse of their greater fullness. The elevation of the juad of the optie nerve. because as the result of lie its indistinct contour its where the opacity ceases. . or a deep. pointed ends.ipilla. the arteries contracted. or at the margin of the opacity. Miclirl: At fir>t the arteries are seen to become . 25). general. the center of the papilla. and are destitute of jiulsation. or only a part of the The excavation may papilla may be affected more and more margins seem to (Fig. according to v. and hemorvessels ai-e hidden. obscured. 2. and The papilla it a reddish gray tone of color that often inclines to violet. from the swollen tissue. the veins. beginning with pale. see page 9. while for a long time. The large venous trunks are much broadened. and exhibits an increasing opacity with radiating lines. appear to be bent and broken on the other give margin of the papilla . which covers its margins. lines. tortuous. the retina in its immediate neigliborhood becomes opaque. Fine. The opacity of the papilla and of its immediate vicinitv exhibits more and more a striated and reddish white appearance corresponding to the normal course of the bundles of nerve Often the vessels can scarcely be perceived in fibers in the retina.is follows. wliile in optic neuritis tlie arteries are almost normal and the veins overfilled.80 are distended. is In optic neuritis the vision (central scotoma). These lines and spots often extend beyond the margin of the papilla and maintain such ' Coneerninfr the way to estimate ditTcrences of level. in usually it much impaired at a very early stage (juite. 24). persist for a while (Fig.i gray edge. choked disk may remain nearly. and is bordered by . have diameters the depth at which they are situated. or small. arteries appear to be tliat still drawn out and dark red ])ale. extends out beyond them. in which they run tortuous courses. into view first in its periphery. of a dark red color. and l)i'nd rhages are often found arranged in radi. or normal The course of a choked disk is . as well as here and there the latter itself. The beh.ivior of the vision. forms a marked elevation with a precipitous descent to the retina. usually in the retina at the in margin of the brilliant p. while a disk the seat of a neuritis seldom reaches such a height. The color. for a distance by a gray opacity. The The smaller vessels veins in become more side of the distinct bcc. *i D.il stria'. white ordinarily arranged radially. but particularly the veins.' A choked disk is accus- tomed to that is rise more than 1 nnn. 3. on and also outside of the papilla. and consequently gives the impression that the papilla has become broader. which appear at a very early period. a large small vessels very often become visible on the pa])illa itself number of (I'ig.small and to be provided with broad reflex stripes u})on the papilla. more contracted than at show vary a great deal according to about with great windings in Frequently the the plane of the retina. brilli-mt white spots. are chiefly to be observed in cliildi'en or young people. 23)- In its further course the elevation and swelling of the pay)illa increases. above the level of the retina. but come first.

of a tumor the angle between the cerebellum and the pons. disk. is indicative of a gumma in the cerebellum . a clioked disk with disturbances of the auditory in and facial nerves. and these are mainly tumors of the frontal brain and of tlie hypophysis. A very rapid including not only the true tumors. the veins engorged. The fartiier back the tumor lies the more certain is a choked disk to appear. the arteries remain small. may be swollen at first (Fig. but it one eye or may perhaps such as a be possible from the accom- panying faults in the field of vision. which its stripes. Just as only one half. and orbit.5 to 10% of the cases of tumor of the brain. may present the same condition as albuminuric Sometimes the veins are accompanied by white reddish tone of color. The opacity and ing do not undergo complete involution. or yellowish white opacity. It must be remembered that tumors or abscesses in the middle fossa of the skull may protrude into the Chohed Disk conditions of the brain that reduce the occurs in all amount of space in the cranial cavity. Gradually tlic papilla loses its is replaced by a white. inclining to gray. and tubercles (about 70 to 80"^). so in the involution of the swelling the subsidence in the may take place same way. but also mata. onset of visual disturbance. abscess. tumor of the brain is The cause of choked disk next in importance to serous meningitis. A disturbance in the field of vision. such . gumChoked disk is absent in onh' from . Not infrequently the pigment epithelium in the region of is the opaque margin of the optic disk decolorized. frequently gives an indication as to the A choked disk with horizontal hemianopsia may bo caused by a hydrocephalus internus with a bulging outward of the recessus situation of the tumor. and gumma. of these changes ushers in the so-called atrophic stage (Fig. cysticerci. infundibuli and pressure of the same upon the chiasm. like a hemianopsia. or h/jdroccphalus internus. None of the other causes. aneurysms. What Etiological Conclusions can be Drawn from the Ophthal- moscopic Picture of Choked Disk? Unilateral Cliol'id Dislc occurs in affections of the orbit. homonymous hemianopsia. with a high degree of choked disk and severe pains in the back of the head. Chief among these are all kinds of tumors of the brain. A localization of a in brain tumor from the greater development of the choked disk the other cannot be made. cysticercus. 23). Bilateral in diseases of the accessory sinuses. in The onset 13) of clioked swell- which the protrusion of the papilla subsides. such as tumor. or one sector.81 an extent and in groupiiitr tliat tlio retina retinitis. but margins remain obscured and the swelling continues to be plainly demonstrable.

the mushroomlike elevation of the papilla into the vitreous. the venous blood into the cavernous sinus. and liLinorrliagic pachymeningitis.82 as oxjccphalia. or subarachnoidal space. taken from the textbook by Roemer. When the atrophic stage the vision gradually disappears.i test he Therefore the urine should made in every case. and the great distention of the sheath of the optic nerve. be examined and Wassermann'. sinus tluomljosis. of iqual c'oiisi([iuiice. or of obscuration. in may consequence of the engorgement that takes place at the same time. side of the lesion The aft'ection is usually more ])ron()uneed on the than on the other. Finally. The vision may remain normal for a long time. In this picture. fleeting attacks of blindness. . vessels of the retina see pages 78 and 102. hemorrhages into the subdural. but from the the patients are tormented by temporary. do not correspond entirely with the {)ieturc of choked disk. a choked disk may result from an obstruction to the outflow of Fig. In the disease last mentioned the witli dilatation choked disk is sometimes unihiteral and associated of the pupil. p.— Choked Disk. Concerning the thrombosis of the Such a cause is supposed to be present in the choked disk of chlorosis. abscess art' of tlio hrain. are to be seen very distinctly. and therefore be at variance the choked disk passes into first with the great ophthalmoscopic changes. inasnuieh as the dispropoi'tion between tiu veins is The affections of the optic nerve observed in ai-terii's and the not apt to be so marked. In conclusion optic neuritis it remains to be said that albmninuric and arteriosclerotic present the picture of choked disk.

For example. are gummata and tubercles. (Is of tlie Optic Nerve in the orbit produce an ophthalmoscopic picture that varies accordingly as severed in the portion that contains the vessels. but such a central oj)tic neuritis is scotoma as accompanies almost never seen. Hemorrhages on the Papilla may appear in optic neuritis. the results of injuries. our.83 The field of vision shows various forms of contraction. 44. Tlie demonstration of a hemorrhage. in the course of about 6 weeks (see Fig. when it is not of traumatic origin. or when the vessels of the .uul page 150). in the Tlic defects may be peripheral.eye. A conglomerate tubercle is shown in Fig. retina are sclerotic. Sometimes they result from injuries to the or to the optic nerve. it immediately decides the question in a doubtful case of optic neuritis or pseudoneuritis in favor of the former (see ]\ page 71). In the former cases the signs of an occlusion of the central artery are present (see Fig. and page 54). . Sometimes developments of connective tissue are seen to extend out from the papilla. or the products of organization of hemorrhages. 10. the most common 19. or in the part the nerve is that does not. is always of great diagnostic importance. or of hemianopsia. or in choked disk. in the latter case the optic nerve appears to be perfectly normal in spite of the blindness. these may be the remains of fetal structures. or form of sectors. until atrophy gradually develops. . Tumors are rarely met with on the papilla .

.

18.PLATE X Fig. Optic Neuritis Fig. Tubercle at the Entrance of the Optic Nerve . 19.

was based upon the local reaction that followed an injection of tuberculin. or by determining the refraction with the ophtiialmoscope. which is shown by j)arallactic disj)lacenicnt to be distinctly elevated. The fundus is of the albinotic type and is normal. 8fi .uiicd l)y whitish stripes on the papilla.Fig. or of a conglomerate of tubercles. 18. in this case. They are acconijj. to syphilis. caused by an a'dema of the retina. The nerve. the papilla is of sjx'cial value in the diagnosis (see Fig. Tiie condition was due. tlic disk itself is much surrounded by a gray areola. nearly as large as the papilla. head of the optic nerve. except for the gray discoloration in the vicinity of the lesion. The gray ring about page 72). It is striking that no completely hidden. in the diagnosis in this case was that of a tumor at the entrance of the optic The specific diagnosis of a tubercle. due to a'dema. The retinal vessels that end at this place y)lunge into the mass and their terminal portions are invisible. A slight elevation of the disk can be made out by parallactic displacement. It is surrounded by a slightly gray discoloration of the fundus. superior temporal artery cm l)e seen. 19. Tubercle at the Entrance of the Optic Nerve (See pages 76 and 83) The larger part of the papilla is obliterated. its margin on one side is At that jjlace is a whitish mass. the retinal vessels elsewhere are normal. Optic Neuritis (See pages 72 and 75) The margins reddened and is of tlic optic disk arc quite indistinct. The veins are much distended and are slightly hazy in the gray zone caused by the retinal oedema.

Fig. 18. Fig.Tab. lO. . 19.

.

21. 20.PLATE Fig. Optic Neuritis Undergoing Involution . XI Albuminuric Optic Neuritis (Albuminuric Choked Disk) Fig.

but. for the}' arc sometimes found in association with it. which accounts for the dark gray discoloration. Fig. its margins arc obliterated. approaches the iiiaculn albuminurica. It was mistaken at first for a choked disk caused by a tumor of the brain. 88 . stipjiled type. that diagnosis abandoned and replaced by that of an albuminuric neuritis (sec page 79). its arteries reduced in size. The The vessels are distinctly sheathed. people. while the marginal portions are paler. Pigment has migrated into the retina around also be indicative of the so-called arterioscleis the optic nerve. for it is in no way contraiiidicases of albuminuric present in by no means all diseases of the retina. and the urine presented the characteristics of chronic nephritis. which its is the tessehited in nasal portion. At some distance from the papilla may be seen hemorrhages phiced radially. These patches of degeneration are not inconsistent with a typical choked disk. a cold red in the center. in is Tile absence of the stellate figure cative of albuminuria. a in old this may form of inflammation of the optic nerve that in the retinal vessels met with intensity. therefore superficial. Albuminuric Optic Neuritis (Albuminuric Choked Disk) (See page 7G) Tlic papilla is very red and swollen. The fundus. — Optic Neuritis Undergoing Involution 7-i (See pages and 76) The margins color is of the papilla have already become rather more distinct. as the result of the neurological examination was negative. 21. and is characterized by a verj' sluggish course of little in which the changes stand in the foreground. but they are to be seen more commonly with neuroretinitis on the whole of the uniform. and some stipplings that indicate patches liad to be of degeneration on the temporal side. 20.Fig. Such a picture as rotic optic neuritis.

21 . Fig. Fig.Tab. II. 20.

.

PLATE Fig. XII The Optic Nerve in a Case of Sinus Thrombosis ComOtitis plicating an Media . 22.

the redness of the papilla becomes greater without causing the margins to become particularly indistinct.Tiiiia of tlic papillu is soiiictinu's seen in iincomplic. The Optic Nerve in a Case of Sinus Thrombosis Otitis 77) Com- plicating an Media (See piigc- A slitrlit liypei-.itcd cases of otitis media. is specially no- ticeable is the enormous (rdema of the retina which surrounds the head of the hides evirything optic nerve and that lies beneatli The retinal vessels may as is rise through the (edema and show a distinct parallactic displacement. but as soon as a ciTcbral complication takes place. an extradural abscess. but the prognosis of this not bad.Fig. the case with the vessel situated above in the picture. as changes that are to some degree distinct have appeared in the it head of the optic nerve This operation becomes the duty of the aural surgeon to open thq sometimes followed by an exacerbation of the intrais is ocular condition. 22. color of the fundus is The wdema cannot be seen as well when the uniform. almost albinotic fundus shows up many details that are lack- ing in the o'deniatous portion. is The (edema and because tlie very clearly visible in this case because it is quite extensive. As soon skull. when they are placed more deeply they are partially covered by the oedema. What it. 90 . The veins show only a trifling congestion. such as a sinus tlironibosis. or a meningitis.

.Tab. Fig. 22. 12.

.

23. 24. XIII Commencing Choked Disk Commencing Choked Disk .PLATE Fig. Fig.

Fig. Commencing Choked Disk (Sl'u pa^re 80) tiie It is important to be rJilc to recognize early stage of a clioked disk on account of its significance in diagnosis. 92 .Fig. — Commencing Choked Disk (See page 80) This picture shows another form. vation has already invaded the vicinity so as to be enlarged and to completely obscure its The oedema that causes the elemake the papilla appear to margins. the remains at is its old level. 23. is while only a part of the arteries show tliat their caliber diminished. The veins are distended. as well as the oedema that surrounds the papilla. while the nasal is distinctly elevated. has not yet been driven forward. while the center arteries still The entire periphery is protruded. 24. where the nerve fibers are feebler. The disproportion between and the veins clearly marked. It can be seen from the course of the vessels that the temporal portion of the papilla.

Tab. Fig. 1». 24. 23. . Fig.

.

Old Choked Disk with a Very Abundant Development of Vessels Fig. 25. Choked Disk at Its Acme .PLATE XIV Fig. 26.

as can be seen a radiating striation.e \eins forms the principal On the papilla are to seen a large ground for the diagnosis. The lesion in this case Fig. The ])aj)illa distinctly elevated. Old Choked Disk with a Very Abundant Development of Vessels (Sec page 81 Two picture. Choked Disk (See page 80) at Its Acme The more diffusi' foi'in is shown j)apilla. The shown in oilier papilla of the same patient. 94 . former are scarcely visible. is indicates that the choked disk has lasted a long time. the other more diffuse. 22.) Fig. this The vision ])atient was normal. The former shown in this The tlistiiict. The disproportion between the arteries and tlic l. delimitation of the swollen portion from the retina althoiiirji is comparatively the protrusion is is considerable. and exhibits in A num- ber of hemorrhages. but they are often much more numerous. forms of cliokc'd disk can be distin^iished in well-marked cases. the so-called acusticus tumor. one is distinctly knob-shaped. this was distinctly atrophic. in this picture. vessels. give the disk quite a specific appearthe arteries and the veins is The disproportion between tiie so great at the the papilla acme that the retina. as may be seen from the course of the \essels. in The neurological examination revealed the existence of a tumor the angle between the cerebellum and the pons. was a ii'liosarcoma of the eei'(l)elluni. while the latter leave as broad. also striate form. which Fig. 26. and (edema also certainly present. Some white patches of degeneration are visible in in There in ai'e only a few retinal hemorrhages this case. number of newly formed vessels. tortuous bands. 25. Scarcely a trace can be seen of the margins of the hut the latter seems to send tonguelike is processes into the retina. from the course of the ance.

25. 26.Tab. . ¥U'. Fio. J4.

.

Vessels of the Retina .

.

and correspondingly to investigate. but only is the wall has to be added mentally. as in Fig. 44. In many as. in Fig. The changes nomena are relate chiefly to the caliber and walls of the vessels. as.Vessels of the Retina Tlie great diagnostic inipoi-tanci' of changes in the vessels of tlic retina has already been pointed out in the study of the diseases of the optic nerve. the cause of such changes in others. in On which the other hand. for example. 28. uiukr certain circumstances. lilood vessels be seen so clearly. needed to . indicates how highly ophthalmoscopy is to be valued (compare page 153). cases the sequela of diseases of the vessels stand forth in such a for example. as the retina. but shauld accustom ourselves to investigate the vessels of the retina very thoroughly. when they are also that under some pathological conditions. is seen ophthalmoscopically not the entire vessel. and. and. think of. that a certain schooling is manner. else in is Nowhere else are else in the hodv can the nowhere they so accessible to direct observation. from a scarcely perceptible veiling 07 . nowhere our duty so imperative to study the minutest details of the picture. and careful observation. its ening that is made evident only by a narrowing is Tlm^ eon- what tents . they may be perfectly transparent in spite of a considerable thickof the blood column. the changes in the vessels themselves are so prominent that they explain tjie clinical picture. so that the vessel it really twice as thick as appears to be be observed in the ophthalmoscopic picture. Wc should therefore not he content to cast a brief glance at the papilla in an ophthalmoscopic examimition. the the vessels of more so that they are offshoots from the vessels of the brain. hyaline de- generation. defects a])pear the transparency of the vessel wall to a may in all ilegrees. Preliminary Remarks on the It Anatomy a normal condition: in must he remembered that tlie walls of the retinal vessels are perfectly in transparent. more rarely to their contents. and therefore invisible. in A special chapter is devoted here to changes these vessels in order to to lead to their indicate their importance in the most forceful manner. and that certain conclusions can be drawn from their condition with referBouchut termed ophthalmoscopy direct it cerebroscopy. pulsatory pheto be taken into account tliagnostically. although this expression overshoots the mark. ence to that of the cerebral vessels.

. 2. at drawn distinctly short- ened. but also to more or the less dee[) situation of the vessel the retina. transformation into white cords. tortuous. drawn out. its breadth and intensity. The refiex and the color are also apt to be changed. up to total disappearance of the vessels. The color: (a) (b) Tlie chancre of color may be tlue to the color of the blood column. The Changes take place in in the Vessels of the Retina A. Diliifiitions. . Tlio color ussiiiiud \)\ tlic liirht noscI . infiltrates in C. in regard to this are to be noted 1. 1. the cause of which . Four forms are to be distinguished ctiologically (n) That which is produced pathologically. or a hrown reflection iiwiy be fairly variable. commonly termed sclerosis. The number and arrangement. The reflex. The Caliber is ConiracHon. Vncvcrnuxscs in the caliber of individual vessels. accompanying stripes. F. the o|)acity and the a »'rav wliitc. D. 3. ELABORATION OF THE ABOVE SUMMARY A. may lioth then he a j)urc wliitc. the color of the k'iiU of the vessel. T^ifferentiation must be made between Contractionn. : 98 coiiipk'tc opacity. broken. or over the vessels. 3. The caliber: 1. The phenomena of pulsation. B. which are due not only thi' to the optical conditions in in the eve. caused by contraction of the muscular tissue (r) that which is in the wall of the vessel due to compression. later it is transverse diameter. ii yellow white. In the observation of the transverse iliainetcr of the vessel the observer is subject to presi'iit many illusions. Dijfcrciiccs in the projiortioinitc ciililiir of the arteries and of the veins. E. i. The apparent size of ])apilla must serve as the unit of measure. wavy. A of its change in the length of a vessel first it is usually associated with a decrease out. is to be sought in a compression of the afferent vessels is (J) that which due to an imperfect filling of the vessels with blood. The course. (?>) that which is functional. 2.

no longer visible. 16). the extremely rare congenital sheathings being excluded. or together. Q). 51). when the vessels disappear the arteries are the to become invis- In the majority of cases the arteries alone are affected. 56. the either and Fig. which arteries both the and the veins. but true It is diminutions and atrophies of the vessels themselves are met with. The high degree of contraction of acquired (Fig. In the latter case the physiological is and the arteries maintained to the first last. 35). acute occlusion of the arteries with its consequences page 1. 44). As complications. iind extensive disease of the retina in the form of retinitis albuminurica (see (see page 133 and Fig. and as the vessels in the same person vary in size one from it is often quite difficult to determine whether a commencing sclerosis present or not. 56). and to the sheathings that These conditions are almost always to be held to commencing is sclerosis of the vessels. If the sclerosis difficulties are encountered in more advanced. the its diagnosis. is x\s appears from tlie above remarks on vessel anatomy. and therefore invisible. 31). disease to be taken into account is syphilis.' to abnormally distinct pulsation. tlie . but while shows itself in by a diminution of the blood column due to an insufficient supply of blood. In such doubtful cases attention has to be paid to fiuctua- tions in caliber. is A found in uniform functional contraction of both the arteries and the veins in cases of poisoning with quinine or ergotin. 27). thrombosis of the veins (see page 117 and Fig. is tliu most coimiion. difference in the breadth of the veins so that ible. for example. 131- 38) or hereditary (Fig. depends on similar causes to is all appearance. chronic nephritis and diabetes. may perhaps indicate a be present. or diabetica (see page first Etiologically. change may go so far as to render the vessels The changes may take place in both the arteries and the veins. not As considerable another.sclurosis.50 and Fig.99 The first form. A compression of the arteries it is associated regularly with a compression the arteries it of the veins. is differences occur normally in the caliber of the vessels in different persons. or (see may be named atrophy of the optic nerve page 53 and Fig. cither in- dependently of each other. and sometimes also old cases of glaucoma. no further As may be seen in Fig. seem to be rather broadened on account of the elasticity of their sequela?. then arteriosclerosis (Fig. . afifects the vessels found in retinitis pigmentosa (Fig. of such a nature that the transjjarciit. 67). while the veins at first walls. in chronic alcoholism and commencing syncope. as in Fig. 67. wall of the is thickenetl so as to render the blood tohunn within it smaller. ^ causes an engorgement it The apparent diminution of the vessel to a point at the place where leaves the papilla is not to be understood as a fluctuation in caliber in this sense. usually possible to distinguish the two forms opiitliahnoscopifully. the contraction usually only an apparent one. Contrac- tion of the arteries alone to be observed as a sequel of an old occlusion in (Fig.

As the con- venous entjorgenient forms most conspicuous jiart of the picture. . If the dilatation involves both the arteries is and the veins the normal difference between their transverse diameters maintained. and as the result of local conges- by contusions. but this usually passes off very quickly checked. this \'es. is by too It is nnieh light. met with in inflammation of both the anterior and posterior segments of the eyeball. or the apoplectic habit. Dilatations of the Vessels. as in a neuro- retinitis may then be buried completely in the oedema. as in operations for strabismus. the former becoming broader. The and the color of the blood column arc also accustomed to undergo a change.sion cbicfly in tlic escape of tlie blood. Ocular causes to which it may be due are the sudden relaxation of tension relief caused by operative or accidental wounding of the eyeball. . such as plethora. or the veins alone may be affected. Just as a straightening accompanies the contraction of a vessel. The color of the fundus is not changed by the increased fullness of the vessels. In this respect inflammation of the optic nerve is to be mentioned as of special importance (see Optic Neuritis. A dilatation of the arteries alone is not likely to be ob- served. which are usually invisible. dition will be described below. for example. by a downward inclination of the head. as when an ophthalmoscopic examination prolonged unduly. which less severe is functional disturbance of the vision persists in many due to a partial or total atro])hy of the optic nerve.ilt after the hemorrhage has been hough a more or cases. as in labor. on the con- livelier color. coincidently a great deal of oedema the smaller and deeper branches . page 72). 28)- Both arteries and veins may be dilated at the same time.100 of the veins by obstructing . or by too great demands having been likewise made on the acconmiodation. reflex so a marked tortuosity is commonly associated with its dilatation. as is the case when trary the papilla takes on a in there is . and in overindulgence in alcohol. the latter darker (see Fig. We iiuct uitli coniprcs- cases of tumor of the orbit it and affections that ri(hiee the space within tile skulh In tiie former tlie is unilateral. the tion produced from pressure.sels. in constitutional anomalies. (rt) Uniform Dilatation of the Veins and Arteries local is met with as a symptom of general plethora in fevers. At the same time it must be remembered that under certain circumstances the number may seem to be smaller than normal. come into view. from ulcer of the stomach and from wounds. 2. The vessels seem to be increased number because the smaller ones. under Dilatation of the A contraction of the arteries takes place in cases in which there has been a great loss of blood. in the latter bilateral.

It is also to first sign of a cerebral complication. The color of the fundus in orange red. and tlie only thing necessary to call attention again to the great importance of this point in the differ- ential diagnosis of optic neuritis 4. In Ieucoc3'thffmia the veins are apt to be enormously dilated. in diseases of the ear. it (e) when when unilateral. In inflammation of the head of the optic nerve (albuminuric choked In compression of the vessels. rarely tracted A'enous hyperaemia is to acquired. varicosities in and tumor (Fig. in 27 and 28)1 the most essential and most prominent symptom (S) which is the enormous hemorrhages. and poly- cyth. secondary glaucoma. as well as in pneumonia. in the brain. for example. Real inequalities in may be caused by uneven scleroses of the walls. is more marked in some places than in and the sense that the wall of the vessel is thickened more on one . is disk) and of the retina (Fig. (/3) contraction ensues in the later In acute glaucoma (Fig. (a) In the early stage of plilebosclerosis stages. page 79). 50)of the veins). 20. uneven both the sense that the sclerosis others. Unevennesses of Caliher in the course of individual vessels may be real or only apparent. or of a sinus involve- ment. from an intraocular (y) In thrombosis of the veins (Figs. 3. from choked disk (page 79). It is to be noticed in those affections which are accompanied by an oedema of the retina that the vessels are sometimes so embedded in the oedema that only a portion of their transverse sections can be seen.Tmia. The dilatation of the veins may be so considerable as to make them appear to be from one quarter to one and one half times as broad as normal. pulsation of the arteries. (Ii) Venous Hyperaemia with the Arteries Normal or Conpresent in general cyanosis due to congenital. either directly by tumors of the orbit. while the dilatation of the these cases is arteries is only moderate. The Differences in the Proportional Sizes of the Arteries and of the Veins have been dealt with is in the preceding chapter.101 It is considered by sonic authors to be an early symptom of disease of first the accessory sinuses which be noticed as the may be tlie very to appear. It is due to local causes: . or by processes that increase the pressure 26). heart disease. emphysema. it is bilateral (Fig. 14.

and masses of exudate (Fig. may affect wall of the vessel witiiout of producing any opacltv within fairl}' and as the breatitli the vessel fluctuates is wide limits under physiological conditions. The vessels are pale in ana-mia. somctiincs only certain portions of The accompanying stripes may be due to various causes. Sometimes they indicate a commencing sclerosis. 37). In the latter disease the color of the veins almost the same as that of the arteries. or in the tissue tumor ( Fig. An apparent change of tlif of caliber may be produced by the embedding of the vessel in the swollen or oedematous retina (see Fig. Although they are to be seen most plainly in the neighborhood of the papilla they are to be found there least often. 50)- A tissue in variation in caliber may also be simulated by the presence over the Partial interruptions vessel of such tissues as medullated nerve fibers (Fig. The change it of color sometimes affects only the sides of the vessels. phlebectasiie of the veins. in these cases the blood colunui is commonly narrowed. to a very marked degree. and and the veins is is in venous engorge- ments of either general or local origin. A vessel that is buried very deeply In the retina appears is to be darker than one that is superficial. is in leucocytha'mia. secondary. so is tliut the Uinieii is displaced from tlie tlie center of the made oval. forming aneurysms of the arteries. the inequality of caliber out of the wall of the vessel. . its when entire produces the appearance of accompanying stripes. 38)- tiirombosed vessels may B.side than vessel. In cases in which the thrombosis cellulitis.^ In most cases they ^ The sheathinps of the vessel confined exclusively to the vicinity of the papilla are usually the results of neuritic changes (see under Proliferation of glia). especial weight tlie to be placed on such tmevennesses of cuUbcr in sclerosis. As in scleroses it. breadth. and. because the smaller vessels are usually diseased before the larger. Thrombi may readily form in the places where the vessels are pouched out. sometimes it. in the color of the arteries In these cases the ordinary difference particularly distinct. in thromboses (Fig. chlorosis. bands of connective (Fig. 33). 28). The Color of the Vessels dependent on the color of the blood. as siiown may in lead to greater or less pouching i those that course upward in Fig. 9). for example. or on the other. diagnosis of commencing Secondly. and of its surroundCeteris paribus a vessel appears to be darker on a bright than on a ings. dark background. of the vessel wall. to an orbital the I'essels are very dark and seem to be almost black. also simulate such an appearance. 36. so that the former can be distinguished only by their greater breadth The vessels are dark and tortuosity.

and other concrements. It has already been mentioned that the indistinct margins and the white color of the papilla in an atrophy that results from an optic neuritis are caused by a proliferation of the interstitial glia tissue and. we the intima and cellular and connective tissue proliferations of adventitia. especially in young persons in whom the fundus is dark. they are spoken of here under two heads simply Secondly. or may blend gradually with the transparent portion of the retina. A third form is shown 42. 2 and 30- . reflex light streak. occlusion within it. it can be explained only as a the lymph spaces of the adventitia with white blood corpuscles. can be seen to accompany the vessel tiiroughout its In very marked cases the whole vessel may finally be transformed into a white cord (Fig. it The color is commonly in varies from other forms of sheathing. but in it may be gray. Sometimes the accompanying stripes are only simulated by the reflection of light along the vessels. after and the entire cord. 12 and 21). The demonstration of such a change a pure white. that occur here and there. The very first sign of such a disease is usually a broadening of the central. or reddish gray. need only to be mentioned. The complete interi-uption of a vessel with the signs of a sudden (see Fig. This sort of reflection is seen very often (see page 26). Pathologicallv. The pure white color prevails find the sheathings to be described below. This is the one that is met with filling of those cases in which an acute sheathing of the retinal vessels appears simul- taneously with signs of retinitis . (IS may be caused by a proUferaiion of the consequence of an optic neuritis (Figs. vessel which the changes develop that have been described becomes gradually transformed into a slender. 37). Such reflections are shown in Figs. in which is therefore valuable evidence in favor of the neuritic nature of an atrophy of the optic nerve. They can be recognized from the fact that they change as the mirror is rotated.3 spread out irregularly' and may have sharply defined edges. the accompanying stripes the gVui.i(). or a thrombus. distinct. white is Generally the color pure white. except that here the fluid has already the sheaths of the vessels. 33 have in a similar to be explained left manner. this sort of sheathing is in tlie harmony with such an optic nei-ve. . The bright bands along the upper vessels in Fig. in Fig. The same as sequeL-e consist of diseases of the retina in simple sclerosis. Sometimes these stripes entire length. etiology. 56). or in in its found only on is immediate vicinity. as the As one a rule the two forms of disease cannot be recognized as passes over into the other for the sake of clearness. The latter may lead to the so-called retinitis proliferans (Fig. or at least it most pronounced this locality. the and the same etiological factors take part. and of the optic nerve. 45) indicates the presence of an embolus. The white deposits of lime.

glaucoma and after thromboses of the As a rule the newly formed veins are the so-called opticociliary veins (see page 23). lie In most cases the^' on the papilla itself. or of the fact that their walls have been made visible. 56)) as well as in injuries and diseases of retina. is no oversupply. regarded as pathological they arc rather to be considered to be physiological connection with other disturbances variations (see page 23). A vessels surplus of vessels may be congenital. The vessels which are to be observed in in the fundus. yet some can be seen in the retina alone. or retinociliary. well as in i. are rarely of a retinal.. 84 and 85)- . or of loops These are to be observed when gross circulatory disturbis ances are present central vein. in vascular engorgement from compression of the veins or When the glaucoma. is seen when vessels that are otherwis(> invisible come into view as the result of distention. or partial obliteration of the such conditions as favor the origin of a choked disk. An apparent increase central artery is occluded the veins about the macula. 36). wlien arteries (Figs. but the deceptive appearance caused by the fact that the which usually divide on the papilla. but usually of a chorioidal or scleral nature (Figs. as in in comjiression.apparent diminution. also been the retina which are associated with a proliferation of connective tissue. They have observed after injuries to the optic nerve and retina. come plainly into view (Fig. 44 and 45). A diminution met with tlie in marked sclerosis (Fig. for example. in the eye. number of vessels may likewise be real or only apparent. as well as in cases of tumor and of detachment A but smaller iuiihIht of vessels than lun-mal is may be present congenitally. is present.104. and in detachment of the retina. as veins. Changes of vessels is in the Number of the Vessels The numbiT may be diminislied or increased. which are otherwise scarcely visible. caused by a new formation of large veins. with a coloboma of the chorioid. An increase in the A true increase of small vessels. The presence of opticociliary. in leucocytha^mia. or after they have have divided before they leave the hilus (see page 22). C. The loops of small vessels are ])articularly connnon 25) they are to be seen more rarely in diseases of . Such an apparent increase is seen in commencing sclerosis of the vessels. and when great u-dema of the retina. especially those that are associated with a development of connective tissue (Fig. An . 45). tiie is to be observed when optic nerve is suddenly severed througli the portion that are occluded contains the vessels. in choked disk (Fig. yet is in most cases there left it.e. vessels can scarcely be . due to some being rendered invisible. in such a condition connnonly associated with other anomalies the fundus.

or be brought connective tissue formations which may be either congenital. is The we look careful study of the course of the retinal vessels in of extremely great tiie importance the determination of differences of level within eve. efficient We can perceive differences of level only by the aid of secondary means. however. seem to be The vessels in myopia. As into the eye of a patient witli only one eve tliis is our stereoscopic perception of depth.e. A number of fresh tubercles are shown along the course of the inferior temporal vein in 78. 72). and in a proliferation of connective tissue (Fig. with its contraction. The Reflex It is of the retinal vessels comes from those places that are vertical to the line of direction of the observing eye. for about by certain pathological processes. as we cannot make use of dependent on binocular vision. in its due to a simultaneous tension long axis. 23). normal as the result of the destruc- tion. On the arteries generally brighter. is among which Fig. and more . vessels. is visible. young persons. especially in . the wavy course of In Fig. or the new formation of D. narrower. is tlie actuating cause. more intense. the vessel enables us to perceive wiiere the tlie elevations are. or drawn out (Fig. tlie is fullness of the vessel. is How important the observation of the course of the vessels in the diagnosis of glaucoma has already been pointed out on page 56. and a stretciving. so much so that we sometimes speak of a The disproportion between the size retina is tortuositas vasorum. of the eyeball and the surface of the the cause of this peculiar behavior. The Course of the Individual Vessel shows some typical peculiarities. The subdivision may also deviate froiii the vessels. jiull example. on is although it is weak and narrow it is it absent. while other parts on the contrary show a superabundance. the caliber. in a 47 is may pictured a detachment of the retina: be folds recognized from the wavv courses of the We judge in like manner concerning the conditions of level choked disk. On is the contrary the course of the vessel very crooked in hypermetropia. in a commencing tumor.105 The division of tlie retinal vessels the normal. so that a marked tortuosity associated with a distention of a vessel. Thus it can be seen in may present certain deviations from many cases that some parts of the fundus This condition usually provided with vessels are destitute of them. yet it strongest and liroadest on the large the minute branches. especialiv when it nmch stretched. but in other cases the size of i. the course of the vessels a very one. of the detached retina retinal vessels. even on vessels of medium size in senile ej'es. by the retina in one direction or another. E.. is of high degree.

as atrophy sets in. 46)the vessel The slightest extravasation or (wlema in the neighborhood of causes its reflex to disappear. toward the periphery at each stroke. no mattei. There is of this reflex. it comparative condition on the arteries and on the in veins. they gradually dis- appear. has . tiie reflex place wliere tlie bend takes place (Figs. In the beginning of an arteriosclerosis the particularly intense. of blood in the veins. The theory that meets with the most favor the one advanced by Dimmer. of the vessel for any elevation. witii i-eganl to intensitv. yet the reverse condition is sometimes met with. as tiie reflected the light. 23. tlie clear its light When increased the blood pressure it is decreased tlie reflex becomes broader. The blood column seems to be driven backward. is to be seen most distinctly in the large vessels at at the place where they descend into the excavation. certain pathological conditions tlir coloi- Under of the arteries approaches reflexes will that of the veins. and tlun thi' be similar to each other. physiological aTul conditions. shown that the reflex remains has ceased. Venous and Artrrwl Pulse. color. hut this idea has been result of experiis ments and discussion. margins. no agreement among authors as to the cause and place of origin Originally it was tliougiit that the surface of the vessel itself abandoned. The more superficial is the situation of the vessel. visible on the arteries after the circulation F. The its reflex may undergo great individual iliutiiat ions. Yet objections can be raised against this theory Elschnig. whih' cainiot be determined Still the individual case what has brought about the change. tlie The almost as useful as level. 24)vessels is The reflex from the totally absent in detachment of the retina (Fig. uiuln\ . a few important points reflex is may be noticed. for example. The veins best suited for observation are the large ones that end in a point or beak at the hilus. tlie reflex.how disappears at the above the level of the retina. Two different pulsatory phenomena are included under the term pulsation . Phenomena is of Pulsation Pulsation of the retinal veins a normal phenomenon which the iiiius. when becomes narrower.lOf) sharply defined than on the veins. In the later course of the sclerosis. the dee])er the vessel. unitoiinil l)r(adtli. wavy course at of the vessels m the determination of differences of slight. that the reflex comes from the surface of the column and from the place of the axial current in the arteries. strikingly bright reflexes on certain parts of the vessel are the only signs of the disease. tlie more less distinct and sharply defined streak becomes. or the reverse.

finally. an arterial pulse. but usually only In old age a distinct venous pulse is indicative of a comin young people. aneu- rysm of the aorta or carotid. as in glaucoma. 2. or an abnormally low blood pressure. pressed by the finger is a symptom of thrombosis of the central vein. when the eyeball is pressed upon by the finger has been observed in occlusion of the central artery of the retina. is only when the relative conditions of pressure are changed. a venous pulse is seen at if first and then. or falls abnormally low. the coniprussion pulse. rhythmic fluctuations of caliber. an abnormally high pressure in the ai-terial wave svstem. is explained by the fact that the vessels The are subjected to an external pressure. . that an arterial pulse can The elevation of the intraocular tension can also be brought be observed. or. are compressed by it while they are less filled during the diastole. and exophthalmic goitre. that a venous pulse is normal and that an arterial pulse is not. an Absence of the aortic pulse increased intraocular tension.107 o/ the refined arteries: 1. prevented by this. The venous pulse is met with frequently in normal eyes. An arterial pulse is always to be regarded as pathological. If pressure is made with the finger about by compression of the eyeball. for wlien the intraoruhir tension is increased. the become completely empty of blood. peculiar behavior of pulsation in the eye. as the pressure is is increased. as after great loss of blood and in syncope. is The ])ulsation of the arteries and the veins. the so-called intraocular tension. example. upon the eyeball during an ophthalmoscopic examination. retinal vessels the pressure sufficiently forceful. cardiac hypertrophy. or when the intra-arterial pressure rises abnormally high. wliicli manifests itself in a greater and less fullness during the systole and the diastole. finally. as in insufficiency. while the vessels in other parts of the body are not. aortic It indicates either an abnormally high blood pressure. which have walls that affortl little resistIt ance. Absence of the pulse when the eyeball is gently mencing phlebosclerosis.

.

Retina .

.

which between them. m . because the retina very thin at that point and consequently the chorioid and pigment epithelium show through with special clearness. layer. is Its center. This is a division which is not simply anatomical. pigment contained the pigment layer and in the chorioid the color of the chorioidal vessels plays a subordinate part. acThose lying nearest to the vitreous are called the inner layers. Preliminary Remarks on the Anatomy itself In an eye that has been cut open the retina presents as a gray. are grouped together as the cerebral layer. The center of the retina appears yellowish.its is perfectly clear and transparent. In the living. inner. as in occlusion of the central artery (see Fig. Nevertheless the layer of pigment epithelium belongs embryologically and physiologically to the retina. The it peculiar color of the macula is suppressed by its tliat of the subjacent tissue. the fovea centralis. cloudy membrane about Vs mm thick. which occupy the inner portion of the retina. When the seized with forceps and removed from the eye the pigment layer witii remains in close connection the outer layer of the the chorioid. 44). the macula lutea. -A this delicate striation. sets of vessels. form what is known as the layer of sensory epithelium. radiating from the papilla. appears only a is little darker than surroundings. is visible in many normal eyes. the outer granular lies and the membrana limitans. with a dark brown point. the fovea centralis.— Retina A. presence can be perceived only by means of the vessels that course color of the fundus is is The therefore not influenced by that of the less retina itself.^ the entrance of the optic nerve is and the foyea centralis. The layers of the retina are known as the outer and the cording to their positions relative to the contents of the eye.. which separates easily from the pigonly two ment layer and retina is closely connected with the subjacent tissue in places. i. those more distant the outer. still darker. F. with its The contrast in surroundings becomes particularly marked wlien the retina the vicinity of the macula is cloudy. as the two layers receive nutrition from different • The is retina is also attached to the chorioid at the era serrata. to be referred to the color of the retina itself.e. but due essentially to the greater or in abundance of the . The outer layers. it is secondary optic vesicle. but is of great clinical and diagnostic importance. while the others. the layer of rods and cones. normal eye the retina so that in it.

I 3 Outer granular layer f ^ / Layer of granules and visual cells Outer plexiform layer ^ J ( Outer molecular layer '^ \ w Layer of horizontal cells \ J Layer of bipolar cells Inner granular layer _^ I S Layer of amacrine cells 3Inner molecular layer \ nner plexiform layer Layer of ganglion cells I \ J [ Layer of ganglion cells Layer of optic nerve fibers Layer of optic nerve fibers Fig. in it rods preponderate mnnher considerably.too nuich l)i' space. are combed apart. The til)ers radiate from the papilla. To cone give a verv rough idea of the anatomy it may fibers. The other layers also blend at this place until only a single layer of cylin- . or parteil the fovea. the fovea centralis. Q. Its margins are a raised.58). The peripheral portions. with the exception of those Layer of pigment epithelium ^B^S^PS^QI j I Layer of pigment epithelium Layer of rods and cones j I Layer of rods and cones Membrana Hmitans externa (. It is only in exceptional cases tliat have medullary sheaths and form a white s[)ot (meduUated nerve fibers. from the temporal margin of the 1(5 (the papillomaculai- see pages and . as the macula is While the number of the cones increases decreases toward the periphery.\V2 A ical full and precise dcscri})Hon of the anatomy would nquin. so onlv thoso points will iiuntioned which . as it were. temporal is side. less often and measures little in its horizontal diameter l. after Oreeff. so as to lav bare the cones at the bottom of the part. Thr layers of nerve fibers consist of hundles of naked fibers the}'^ which lace. in the inverted image of course inward and upward. and in center is a depression with level margins. The number of the cones increases toward the fovea at the be imagined that the expense of the rods. where the IJoth cease at the ora serrata. sec Fig. Anatomy cnniinw from its of the Retina.d)lc cliniiei'vc importance. rounil.T to 2 its mm.ulu(l. ai)])r(i. The macula is situated about ll^ papillary diameters (i mm) outward and a little downward from the entrance of the optic nerve. The macula it itself supplied by particularly paj)illa fine fibers which run directly to i)un(lle. at and with them their connections. is usually transversely oval.n\- of c^)n^i(l^^. 9). like hair. The construction of the retina undergoes changes l)oth at the macula and at the periphery. which are of clinical interest. wliicli circle in a great arch about the macula. into a plexus.

and of the absence of region of the macula.e.: . The former supplies the cerebral layer. hcnuatii which lies the pigment layer. the central vessels of the chorioid. the fine retinal vessels end in a circle of capillary loops on its margin. lie. The layer of nerve epithelium is entirely without blood vessels and re- ceives its nourishment by diffusion from the capillary network of the chorioid the fovea centralis is likewise nonvascular. tlie it passes over to the is The nutrition of the retina derived from two sources: 1. pass over the the deeper former the changes are deeper than the vessels and therefore laj'ers of the retina ai'e in (Fig. retina indicates a disease of its outer lai/ers. 1. the change must be upon the retina. can be determined ophthalmoscopically If the latter From their relations to the retinal vessels. toward the sclera.seascii of Ophthalmoscopic Differentiation of of the Retina the Inner and Outer Layers and of the Chorioid its As trition the pigment epithelium as well as the neuroepithelium receives nu- from the choriocapillaris of the chorioid. a chorioretinitis: diseases of the retina uithout on the contrary. is yet in the majority the following statement The appearance ment. 11 !3 driccil cells is left. the depth at which they 1. General Diagnosis Di. 2. its inner layers. Although correct: rare cases a pig- mentation of the retina may take place as the result of a retinal hemorrhage. or of the chorioid. the vessels are partly the superficial layers (Fig. 2. . Physiology. but are always covered by a few bundles of nerve fibers. and of abnormal accumuhition>t of piginvohement of the pigment are. the latter the layer of nerve and pigment epithelium. 31 )• If. of The Position i. and the hemorrhage. The principal branches of the central artcr/j of the retina run close to the inner surface of the layer of nerve fibers. but of a chorioretinitis.. in the example cited. of the perfect transparency of tlie Hence the necessity vessels in the retina. in the of pigment stains. of tlie Cliaiiifcs in tlir lleliiin. the changes lie in 33). or project above this into the vitreous. & B. the appearance of pigment is changes the characteristic in symptom of the ophthalmoscopic picture pro- duced by a disturbance this vascular region. or wholly covered. first This gives the peculiar condition that the rays of light must pass through the entire thickness of the retina in order to reach the organs of perception. in its outer layer. on the contrary. but these lie The percipient organs of the retina are the rods and cones. it forms an intimate connection as artery. with whicli iris. Should the vessels be completely hidden. On account in of the simulin these taneous involvement of the retina and the chorioid we do not speak cases of a retinitis. is called preretinal. as by a hemorrhage.

From their form and arrangement. together with the pigment epithelium. and is manifested is in cumscribed bright spots. here. in spite of their i-adiation. is must be taken into account Usually the form of diffuse. which lie.114 2. inflannnation and detruneration can scarcely bo condi- discriminated in the ophthalmoscopic picture. derive their nutriment from . irrefrular. in the sensitive tissue of the retina. in the it is Unfortunately the manifestations diseases are remarkably alike. they usually exception to this rule is the most superficial layers and follow in them the course of the nerve fibers. yet this much can be learnid. while the outer.ition. In such a case it is our imperative duty to submit the body to a very thorough examination. He or inclined to be round. in the deepest layers of The name nothing to do. 32). said to have retinitis. Are Alterations The in the Pigment Epithelium Present or Not? inner layers of the retina are nourished by the central artery. vessels. and the pathological tions that have been found in other similar cases in order to be able to determine the disease in any particular case. products of or the results jjroduced by altered vessels. 34). with its very small capillaries. or cir- that which called retinitis. in or accompany the larger vessels (see Fig. 35)seen in An formed by the stellate patches in the macula albuminuric retinitis (Fig. in the 3. lie. To be sure. Betiititis. pay- ing particular attention to the urine. deeper layers of the retina. or bright spots. usually has to be learned from the results of a general examination. or hemorrhages. The presence of these shows that the changes the retina. in Sti'iatid putclies or liemorrhaf^es foi-iii (Fig. 28). the result of diseases of the The extremely change retina. From the presence or absence of anomalies of pigment. Even a (jrii- though it is not always possible to make the etiological diagnosis from tliiit the ophthalmoscopic examination. lie in When tliey are the deeper layers (Fig. in part at least. opacities. reacts with great ease to any disturbance of circulation. and likewise any composition of the blood or tissue juice leaves first its trace in the visible in the Often the very it signs of a general disease are made retina because is so very sensitive. crtil disease is present in oil cases in xehicli fresh changes arc found in the form of white or black spots. retinitis is used to indicate things with which infiammation has is A reform of ophthalmological nomenclature greatly needed As soon as hemorrhages. no matter whether they are dei)-ener. so that etiological diagnosis can be eye of the various constitutional only in rare cases that the exact it made from the ophthalmoscopic picture alone. or dark spots are visible in is the fundus. the patient foci of inflammation. especially such as extend the of rays from the papilla. or of hemorrhages.

which need ultaneous atrophy of the chorioid.) These are mainly Hemorrhages. to be seen. too. when the sclera not laid bare by the simwhite spots. whether is alterations are present or not in the pigment epithelium.e. in Depigmentation lays bare the tissue of itself is the chorioid and allows the chorioidal vessels. may manifest tlie itself in two ways. either as a depigmentation. are diseases of the optic nerve often in the retina. Special Diagnosis We have made quite a digression into a rather theoretical to the practical diagnosis. These often. The alteration of the pigment epithelium i. will guide us further. field and will now return We liavc studied the papilla and vessels its vicinity with tlie greatest care.. White Spots. diagnosis see page 125. for the answer to this question is decisive with regard to the seat is of the disease and the vascular system that affected. or as an abnormal accumulation of pigment. which are more or less changed such cases. first We will be guided by the question. Disturbances in the central artery of the retina therefore are layers. the reason why the question. us has been already pointed out. and now we turn to the diagnosis of the special diseases of the retina. Are Pigment Changes Present or \ot? and will deal first with Retinal Lesions Which Exhibit No Alterations in the Pigment Epithelium (Diseases of the inner la^'ers. and Diffuse Opacities. This gives rise to to be differentiated from the white spots of the retina. wo have observed the retinal from the various points of view. an atrophy of j)igiiient layer. Hemorrhages and will wliite spots occur together very So. those in the chorioid in tlie made manifest by in is chanjfes in the inner by changes This the outer layers and particularly pigment epitlielium. combined with these changes Hence we make the following subdivisions in order to proceed in the differential diagnosis: . For the differential C. Naturally all three disturbances niaA* be present at the same time. of such great im- portance.115 the chorioid.

After hemorrJiage. circumscrii)ed })atches. striated hemorrhages which radiate from the papilla the layer of nerve fibers. retinal ves- sels lie in front of the retina and are called preretinal in i)e they are usually round. and glaucoma can he excluded hemorrhages are alzca//s signs of a They form a siuiial of warniri"-. tlic importance of the subject: 117((7( injuries. 20.xtent . sometimes we find little. hut this definite statement may be repeated on account of general disease. make a general examination. which can be seen only after a very careful search with in be given the physician —and the upright image alone. as to cover every detail. it Even when the hemor- rhage as sliglit as that to be seen in Fig. The number also of the hemorrhages may vary extremely. the hemorrhages On that fine. 27). in form. high myopia. there is somethiiiii. As regards the depth at which they are situated it has already been said the other hand. I. noted: the position of the hemorrhages relative to the papilla. II. whether they are diffusely distributed.s have been found special questions arise cojtcerri' ing their size.116 /. Diffuse opacities. . abundance.out of in the is order organism . The only precautions to be observed are those given page 11. while roundish. and are found for the most part Topograj)hically the following points have to the region of the macula. and e. this The only advice that can skill implies no question as to his — is to dilate the pupils in a doubtful case in order to be able to make a more accuon rate examination. or oval. and to the large vessels. (a) Hemorrhages as the Only. Hemori-hagcs may be of the most varied the pupil dilated. and position. perhaps in combination teith changes in the retinal vessels: {!)) connection :dth diseases of the optic ner-ee and spats uitli its r^icinil//. and to make the fundus look like a single lake of blood (see Fig.ise. III. or lie quite superto be ficially in lumpy ones are sought in the middle or deep layers. \\ liite or uithout lictnorrliat/es or diseases of the oiitic nerve. or the most importiint change in the retinii. may be so massive as to form the most prominent feature of the ophthalmoscopic picture. to the macula. Hemorrhages that cover the . HEMORRHAGES in the Retina. and whether they are in the vitreous. Hemorrhages: («) As in the onl/j. or the Most Important Change Aftor wliat has heuii said it may scxiii uiimctssarv to call attention to thu significance of hcniorrhaircs in the fundus. may and must be made the starting-point of the diagnosis of a serious dise.

while the The veins are dark red. its caliber varies in different places. inversely. while old ones are of a dark. or nephritis. and the differentiation of little use. glaualso be the cause of iiemorrhage (see coma may page 120). cohnnn of blood. and tortuous is only visible artery small and exhibits a strikingly dis- tinct reflex lijjht streak. until they finally disappear witiiout rule. or of nephritis. From the position. Based on These Findings? is It 1. On the other hand.: 117 Small hemorrliagcs come from vessels. in places. Is a Differential Diagnosis Possible. The cause arteriosclerosis. syphilis. large ones fioiii tlic larger often impossible to differentiate between a venous and an arterial is hemorrliaee. wliicli in turn become invisible. blood red. This clinical picture was named by V. but. Michel apoplexia sanguinea and compared by iiim with corresponding hemorrhages in the brain. which indicates a wall. and therefore If the prognostic signification is (see page 153). The impairment of the functions of the retina depends on the situation. except above and very close to the papilla. in many cases If we find as extensive a hemorrhage as that shown the extent. Note. commencing sclerosis of the vessel The papilla is still fairly visible in this case. is and is filled by a very dark. it is accompanied by abnormal reflexes. margins are totally grave The thrombosis is a consequence of arteriosclerosis. When ditt'ei-eiues in color are to be seen they are to be ascribed to the different ages of the iieniori-hages. The thrombosed vein is broadened on the wiiole. as shown in Fig. consequences of a severe intraocular hemorrliage. almost black. l)rown red. 28. leaving any traces. but in this one they can be studied very well. and their sible An attack of glaucoma may be mentioned as one of the possize. hemorrhages may last for months. struck by the fact that we cannot actually see tlie vessels. wlien hidden. It is tlie capillaries. we can confidently base upon it the diagnosis of thrombosis of 27 the main trunk of the central vein. or perhaps of its syphilis. the force exerted at the time when tiiey occurred. hemorrhages are not spread all over the fundus. as fresh ones are of a bright. When we study the details of the picture we are From in Fig. it is only in rare cases that masses of connective tissue and pigment remain as traces of a hemorrhage. especially when tlie vessel itself shows The vascular changes could not be studied in the last picture on alterations. or tiiey become transformed Into wiiite sjiots. but its frequently it is in- volved in the area covered by the hemorrhage. The absorption of hemorrhages takes place pretty slowly as a The spots gradually become darker. •2. . we may speak of a partial thrombosis. but only occur along one or more vessels. almost black. account of the enormous number of liemorrhagcs.

The causes of a retinal hemor- rhage are very many. lakelike ones both forms usually appear at the same time with white spots.507c. tke form of the latter characterized the granular atrophy of the kidney. so . hemorrhages result from contusions. and are particularly common when the eye has been struck by a ball. Little shuttlelike hemorrhages. from is followed by apoplexy in only about 50/i . because the arteriosclerosis that may may be complicated by other diseases. Finally. ami an injury can From in its the form. each with a white spot center. is They may appear congenitally as the result of trauMore rarely they are to be seen as the result of the Emphasis in this connection. especiaUy by little. rosis may be mentioned. and of 'large.118 Isolated hemorrhages excluded. No definite etiological conclusion can be drawn all any other case from in the condition of the hemorrhage. Their most important cause are of very great prognostic is arteriosclerosis. as shown in Fig. that arterioscleitself through a hemorrhage into the vitreous. They sions of the thorax. as they are often present penetration of a foreign body into the eye. are very important causes both of . by no means neces- sary that the eyeball itself shall be wounded. but they are also found distributed about give a very in the retina as diffuse spots. for the sake of completeness. stippled hemorrhages. 29. These hemor- rhages have been studied already under the forms of total and partial thrombosis of the central vein. Reference is to be made to the chapter on "The Changes in the Vessels of the Retina. The Causes The first of a Retinal is Hemorrhage It is cause to be mentioned an injury. exist Such an examination must be made cases that have been mentioned as well. In other cases the result of the general those examination must be awaited. to be laid on the invisible word "seen" though because of the hemorrhage that takes place into the vitreous at the same time. in in these cases they are value at least . while a thrombosis it bad prognosis with regard to the later onset of apoplexy. and because. or disease of the optic nerve. in the niiU-iiln is are usually <>f an arteriosclerotic l)e nature when a high degret' of myopia not present." and the very careful study of these vessels is urged upon manifest the reader. matism during labor. may Diabetes and nephritis. are connnonly caused by such diseases of the blood as in anaemia and leucocythaMnia. 3. and of the isolated hemorrhage in the macula. they forerunners of hemorrhage into the brain (see page 153). such as compres- in the examination. which 80 to lOO'/c. In these latter cases special attention should be paid to the macula are also found after severe injuries of the body.

influenza. This etiology is always to be borne Syphilis is in mind when the hemorrhages are isolated. that looks as if cut out w ith a punch. First among tluin come tlie diseases of the blood. Conditions that need to be differentiated from retinal hemorrhages are: 1. usuall}' males. scurvy. is As the so-called recurrent hemorrhage into the vitreous hemorrhage from the is looked upon by many autiiors as a retinal vessels. as they are all rare. The vessels of the retina. miliary tuberculosis. These are dark and usually are found 4. The appearance is of considerable importance. in the chorioid. on the so very fre- contrary. hemorrhagic diathein as well purpura. These lie at a deeper level than their surroundings. a spindle. but other manifestations of the disease are usually present. dirt'use (. It hardly needs to be said that they occur in the sis. but they are of comparatively of hemorrhages importance these diseases. of the last mentioned disease the orange tone of the fundus and the great breadth of the vessels arc diagnostic. they are more common in pernicious ana'mia. cjuent in them. Hemorrhages are rarely met with in chlorosis. and sometimes allow the markings of the chorioid to be seen through them. or shuttle shape with a white spot in the center. Similar hemorrhages are also observed loss of blood. it shoidd be mentioned in this place. in company is The traumatic perforation acterized by a circular blood red 5. and Barlow's little disease. typhoid fever.50). chiefly in the form of stri. purpura ha'morrhagica.-e. . Lacerations an opaque. have a distinctly opaque. in the acute infectious diseases. 2. All of the remaining causes are much less frequent. cloudiness of the retina these cases makes the diagnosis certain. such as malaria. pass over them. likewise one of the principal causes of retinal hemorrhages. and perhaps of the chorioid. This is rare and char- disk in the macula. with changes in the chorioid. in simple an<pmia following a great and as in in ha^iiophilia. as can be proved by parallactic displacement. Hemorrhages in the when the fundus contains chorioid. but may appear simply as small spots and stripes. This met with in young persons. It has already been said tiiat these hemorrhages often present a special form.f page 1. 3. little These are rare and demonstrable only pigment. gray margin. yet they may not have this peculiarity. and sepsis. though they are not Sometimes they are to be seen in in cancerous cachexia. Spots of pigment. and occur most In well marked cases often in leucocytha-mia. about two thirds the size of the papilla. of the macula.119 the description of them is reserved for a later cliapter. detached retina. The cherry red spot in occlusion The demonstration of an acute. Other changes are general! v present They are of practical importance onlv in mvopia and the central artery (see in eclampsia.

must lie in the layer of nerve fibers. striated hemorrhages. or blotlike spots. the papilla in optic neuritis from all manner of causes. may be mentioned the hemorrhages that take place or during operations on glaucomatous eyes as the result upon the vessels of the sudden fall of the intraocular tension. which. allow the in details of fundus to become sch-ii again. varying form and number. (b) Hemorrhage into the Retina as an Accompanying Symptom of Disease of the Optic Nerve Glaucomatous Excavation. after an acute attack visible of glaucoma. Choked Disk.120 and lias tlic is unpleasant tondtiuv to recur tliat is impliid Ijy the iiainc. though it has hcin supposed to be due to an early. from their form. Fine. but the}' are particularly common in that due to nephritis and The great diagnostic importance in of these hemorrhages was pointed out when speaking of the so-called pseudoneuritis. The presence of a single minute hemorrliage a doubtful case of pseudoneuritis or optic neuritis immediately renders the latter diagnosis positive. (without white or black spots) As soon as the media have cleared to up the sufficiently. . In this connection after. localized arteriosclerosis. Tlie real cause unknown. The prognosis generally bad in such a case of glaucoma. can be less in addition to the excavated papilla and the more or altered blood vessels. Hemorrhages are found near diabetes. which radiate from the papilla far out is the periphery. Usually they form into little linear. form an almost regular feature of choked disk. hemorrhages. Optic Neuritis.

of a Single Vein of the Retina .PLATE XV Fig. Occlusion of the Central Vein of the Retina (Apoplexia Sanguinea Retinae) Fig. or Thrombosis. Occlusion. 27. 28.

sliirhtly (edematous (see page IIT).Fig. and are also in part thrombosed. or Thrombosis. but it may be covered by the hemorrhages. 122 . The papilla itself is not materially changed. of such an occlusion is nephritis. in the vessels. can be perceived quite well The thrombosed great deal vein is very broad. dark red. tlii' The part. portions of the I'etina between the hemorrhages are vessels are. which could not be the seen in the preceding of profuse hemorrhages. so that only those jiortions closely adja- cent to the papilla are visible. or arteriosclerosis in most Fig.' jiii^t' 1 IT) The ated that in lie striated iirraiif^ement of till' tlie 4ieiiiorrlia^es tlu' sliows tliat 'I'he they are situ- most superficial layers of for the most retina.(.small (see is fre- page 117).— Occlusion of the Central Vein of the Retina (Apoplexia Sanguinea Retinae) (S(. — Occlusion. eoiicealeii by in tlu- hemorriiages. The cause cases. of a Single Vein of the Retina (See page 117) The changes picture because in this one. 28. The arteries are normal in these cases. has abnormal reflexes and has a marked tortuosity. 27. is of a deep. yet the afferent branch quentl}. fluctuates a in caliber. vessel The hemorrhages are in the innnediatu vicinity of the diseased and thereby betray the cause of the change.

e. 28. . 27. Fig.Tab. Fi. 15.

.

Foreign Body in the Retina and Chorioid . 29.PLATE XVI Fig.

I'his ])iece of steel hemorrhage and is surroundid was removed by means of a magnet and good vision was j)reserve(l. latter is absent it is generally possible to obtain a glimpse of the foreign body. is The b}' torn phice partially covered by a an (edematous. irrav. because of an accompanying luniorrhage into the vitreous. Foreign Body sil\rrv hit of fiiiic. Tln' liltlr. hut the hitter may be badly impaired is by the onset of a detachment of the retina. 29. it in the Retina and Chorioid enough to jjcrforate way into the retina and sti'cl (lid not have force its the evehiill a second chorioid. The picture usually if wry this indistinct. gray oval.Fig. wlicre it could only tear remains. 12i .

Tab. IG. Fig. 29. .

.

38. Hence the general symptoms may guide us wrongly in these cases if we do not know that hemorrhages occur far more often in septic retinitis than in miliary tuberculosis. WHITE SPOTS IN THE FUNDUS Question 1 Is the White Spot in the Retina. we need nothing more to prove that the disease is of the chorioid. clinical We nmst be guided many times in this way by our general and pathological experience in deciding whether the lesion is in the may fail if we do not use at the same may appear in sepsis. for example. and when. . for example. which may retina. The reason why is apparent wlien we consider that in many cases. in spite of the fact that we can see onh' the secondary symptoms in the retina. Spots seem very like those of miliary tuberculosis. but only to show him by this example that the answer to the question xchethcr the is lesion is in the ehoit rioid or in the retina. and therefore be attended by quite similar general symptoms. Unfortunately these positive signs are not always present in Fig. but they are situated in tjie by pathological examination. we know positively that the lesion is retinal. 74 that the patch is surrounded by a beautiful wreath of pigment. Still. or to stump a young ophthalmologist with such an unsatisfactory case.case whether a certain white spot in the fundus in the retina or in the chorioid. or in the chorioid. we do not see the chorioidal affection itself. a simultaneous involvement of the optic nerve points rather to the latter. but this time our special ophthalmological knowledge. retina. or in the Chorioid? iSpots) {Differential Diagnosis hctxceen Retinal and Chorioidal it Unfortuii. 81. on the other hand.ittlv tliurc is no qiiiti^' exact ruk' by which can 1)l' determined is positively in ever>. When we sec. but have to be satisfied with symptoms which are produced b}' a lesion upon the retina that lies over it. as in the case of miliary tuberculosis pictured in Fig. we can make the diagnosis of tubercle of the chorioid in this case. as has been proven while on the other hand. 31 the vessels . in Fig. we A see in Fig. not to he learned through the vision alone: is to he ohtained only from the most careful consideration of the other conditions in the eye and the utilization of genercd clinical and pathological knozcledge. because our clinical and pathological experience is that under certain conditions of high fever and stupor the appearsuice of circumthe observation of the secondary in the chorioid scribed patches of I'etinal (rdema in tile fiuidus are inilicative of tubercle of the chorioid. of a circumscribed oedema. certain in one number of SA-mptoms can always be found whicii will make the diagnosis way or another in any given case. I do not wish to make a cai-cful observer timid.125 II. that the white spot lies partially over a vessel in the retina.

the partially albinotic fun- because of the opacity of the elsewhere transparent dus in Fig. nerve indicates a coloboma of the chorioid. oidal whether sclerosed or not. changes are probably present both membranes. but with pigment. A large white the confluence of smaller patch below (in the inverted image above) the optic spots. yet in the one ill lesion is the retina.: : \26 of tlio iTtina run over the vhite spots. (Fig. membrane (Fig. Pigment deposited about or on nal vessel by a white spot 2. 2. Position Very rarely in the periphery. 35). — If both in varieties of spots are found in in any case. 2. Trusixcortliii i. Adjurinit St/mptoms: Uctinal Lesion Bright. in the spot 3. and yet there are heaps of pigment at upper margin. reddish yellow. 38 ) the sjwt (Fig. often brilliant white. 57. 50. and of changes Fig. Chorioidal Lesion Fresh: yellowish. of chori- (Fi-. 34). or nearly so. and an older disease of the chorioitl. Chorioidal Lesion Lesion leti1. and those that are adjuvant. 64). 71). 1. A markedly rhages the retina. N. slightly Color: more gray. These can he accepted only thi' in |>ositivc sense. Usually small. sijmptoms. perhaps due to hereditary syphilis. thus. in the retinal vessels is relatively cer- tain (Fig. cresccntic form. their absence does not prove Ncti/itil contrary. In the case of a tesselated or albinotic fundus the vessels Visibility the case of a uniform. Edematous spots white. stippled fundus the vessels of the chorioid stand forth of of the chorioid are usually invisible in the vessels of the chorioid the vicinity in of the change the retina and indicate early changes Notice in that membrane. as The demonstration in of liemorin . Therefore we lia\e to ditl'erentiate hetween symp- toms that are trust wortiiv. Fig. The partial covering of a ( Fit.e.. In this case there was a fresh disease of the retina. Old: reddish. 1. B. rarely yellowish or gray. and in Fio-.-. glioma.3. Often In in the j)eriphery. or formed by Size: A'ariable. 83. in Differentiation hettreen Lesions tlie Cliorioid (ind the Retina. tlic 81 in tlic wliite s])()ts have the no [jignientcd borders. and tiiose in other the cliorioid. . 22). the retinal vessels its are partly covered by the spot. A stellate form in the macula The demonstration vessels.

or yellowish gray color. in their vicinity. —Attention just like is called to a possibility of error that arises from mistaking reflections from the retina for pathological changes. and because of the anomalies of pigment occasionallv to be ob- served. When other symptoms must be of sympathetic intlannnation are jiresent at the same time the diagnosis cannot fail to be made. yellow or reddish in spots are to be seen arranged in a the macula. they are small. Pathologically. but thev disappear the direct method. defined spots. yellowish white. little exist. Sometimes there a brownish tesselation in their vicinity? is although a true pigmented edge. in ihc Hi-thui. or a marked accumulation of pigment. as this leads in black lumps can generally be seen Little sharply 3. of a yellowish. and have is tendency to blend. but we must look upon them as appertaining to the chorioid because of the nature of the disease as a whole. which indicates a retinal affection. A number circle of fine bright. the other arteriosclerotic changes in the eye. picture which is quite similar The results of the general examination. and is necessary that wc should be acquainted with these in order to avoid falling into error. knoblike thick- enings of the vitreous lamella of the chorioid. These changes arc due to a circum- scribed Jiyaline degeneration of the choriocapillaris. 2. Formations on the Vitreous Lamella (Fig. B. is sympathetlittle They are usually round. 40). which mechanic. arteriosclerotic changes the macula (Fig. or reddish yellow in color. surrounded by a slight pigmentation (Fig. Little Foci in Sympathetic Inflammation (Fig. (a) Changes 1. in Aside from this circular arrangement. when the pupil dilated and the examination made by rotated. and are usuilly indicated by the atrophy the retinal arteries. 41). The coi-rect diagnosis i. 62) to that presented may form an ophthalmoscopic by the corcnula. 16)of the optic nerve and the extreme smallness of (b) 1. N. change their forms when the mirror is After the diagnosis of a disease of the retina has been established above manner there arises in the . in The coronnhi. For this reason. must all be taken making the diagnosis. some authors believe these spots to belong in fact to the retina. Changes in the Chorioid. Colloid as little. are to be seen sometimes in the periphery of the fundus of an eye that ically inflamed. more rarelv oval. patches in the is These may appear They also little yi'llowisli macula.dly destroy the pigment epithelium at the places where they turn to accunudations of pigment. But. absent. into account in and the age. whitish.127 In spite of the diagnosis all this hulp there remains quite a number of cases it in which may be doubtful. These appear bright points. a case in which a total occlusion of the central artery took place at some former time. which can be from the typical spots in differentiated the retina by their color and by the indistinctness of their outlines.

lie divided into two: with regard to the pathology. it which agrees throughout with the description given of medullated nerve although papilla. by the absence of any other lesion. in hai-niony with and thus partly cover the vessels of the retina.' fibers. their anatomical development. so of tlie seems best to deal with them separately. The great stress that is to on the latter condition is shown by the lesion pictured in Fig. where they They are for the most j)art slightly often terminate in a fiamelike figure. though occasionally separated from it. Medulhited nerve a congenital anomaly and are therefore of no other clinical importance. After these lia\e been excliidid conies Question 3 Of What Nature Are This question must 2. The spots may differ greatly their pathological construction. but rarely happens that such fibers overlap the entire margin of the is proved not to be such by the fibers foi-m little hemorrhages at the margin of the lesion. with regard to tiie etiology of the spots. 32. and connnonly are in immediate connection with the papilla.128 Question 2 Is This a Case of Medullated Nerve Fibers or Not? nerve fibers occupy it ii Mc'dulliiti'd unique position anion^ the . is The entire nature wiiilc all condition expressed by the term nuchiMatrd nerve til)ers. which is particularly evident at the margins of the patches that they form. . other white spots in the retina are only symptomatic of causes that must be ascertained through other conditions. or. when they follow the course of the large vessels. ill the Spots in the Retina? 1. but the difficulty is removed by observation of the markings of the fibers and. and yet arise from the same causes. DiagnoKis and Imporlaiirc of Mfdullaii'd Nei've Fibers. on the other hand. yellowish in color. Medullated nerve fibers (Fig. They radiate from the papilla and show a more or less distinct fii)rillati(in. corresponding to the course and the construction of the fibers.iffVctions of the retina. 9) are quite superficial. The diagnosis is somewhat more difficult in the latter cases. above be laid all. they may be due to quite different causes and present the same pathological picture.

especially tubercle nodules. with obliterated margins and a distinct elevation. to be seen in such cases we in tlie chorioid. liferans. The development of connective tissue is caused by hemorrhages. by lacerations of the chorioid and retina. it wiiich can be determined particularly well when retinal vessels pass over (Fig- 78). or from their adventitial sheaths. in a Tliese small number of cases. those in which usually do not enter into at the question (for these see page 149). diabetes. The color is like that of medullated nerve fibers. The diagnosis particularly difficult when wdema occurs its the same in time with other affections of the retina. or to hyaline degeneration. as in Fig. (Edema. It is then usuallv found over fresh choriorctinitic lesions. 1. except that it is it rather duller. and thev often have a similar striated structure. of Aside from the tilings already mentioned. The wiien light it diagnosis is easy only when it occurs in isolated patches. Although only the oedema of the retina is are accustomed to make from it tlie diagnosis of a lesion 3. naturally present no typical arrangement (Fig. —Only is those cases in which the a?dema diffuse. The varicose thickening of tlie lai/er of nerve fibers has the same sublatter very stratum as the medullated nerve fibers and often resembles the . except in the rare cases In the majority in which it is present congenitally.129 Question I/. in the third place. to fatty degeneration. to deposits of calcareous matter. In how far can the Pathological Construction of a Spot be Deter- mined from the Ophthalmoscopic Picture? Differential Dtugnosis of White Spots from a I'atIii)lo(/iriiJ Standjioiin Leaving mcdullatud due to connective iktvl' fibers out of consideration. manifests itself in the form of medium-sized. to fibrinous or serous exudates. or. roundish spots of a gray color. then comes syphilis. to varicose thickening of the layer of nerve fibers. arteriosclerosis plays tiieir the most important part in etiology. is is. Connective Tissue (Figs. 36. 82). from the vessels. to proliferation of the glia. Usually can be level determined by parallactic displacement that they project above the the retina. to wdema. white spots may be tissue. marked and project it is far into the vitreous. and of cases it starts consequently is almost always seen in connection with vessels that are either These are cases of retinitis propathologicalh' changed or newly formed. but presence may be suspected every serious retinal disease. and. as it circumscribed are included here. In the latter disease the masses of connective tissue are particularly well 2. 36 and 37)- — The presence of connective tis- sue always indicates that a serious disturbance has taken place in the retina.

and tin n defined. golden tlie wliite. and the internal granular la^-er. while older ones are reddish and defined. In mild symptoms undergo involution its after some weeks and the eye may return to The ill little normal condition. much less degree. retina 31)) small. the macula is brought about by the fatty degenerais tion of the supjjorting fibers. None of the otiier pathological changes mentioned above can be recog- nized with certainty from the ophthalmoscopic picture. in choked disk. according to others. the so-called synchisis scintillans.e seen sometimes When tlie latter are situated in the most posterior floating in the vitreous. The altcnd in fibers are of i\ light. which have a different nutritive supply (see The This stellate figure in page 113). and the fact that they can be seen when we simply throw light into the eye. . like bits of cotton. or pure 30 !ind produce large spots. To it are to be ascribed the white spots ordinarily be seen in albuminuric white (Figs. blend with their surroundings. but chicfiy in nephritis and diabetes. the layer of ganglion cells. Fdttt) Degeneration. The spots thus produced are larger than those caused by fatty degeneration. The Course of the changes that have been cases the mentioned is usually very slow. retinitis. but to a in the layer of yisual cells. tile and radiate in striie from papilla. This chantre is met with in greatest variety of diseases. — layers of the vitreous they may perhaps simulate s])ots in the retina. 32). but their great parallactic displacement. N. or.130 closely. iti of fat are also to be found the layer of nerve fibers. and sometimes they induce a slight elevation of the ])art affected (Figs. fattj' degeneration met with in all manner of diseases. prove them to be what they are. Sometimes little glittering points or needles can be seen in the These are crystals of cholesterin. Fresh spots are therefore ill bright white and nIku ply defined. quite superficial in situation (Fig. Fibrinous exudates may lie in any or the inner layers of the retina and consequently may be in various relations to the blood vessels. such as are to l. They appear ophthalmoscopicaliy as yellowisii. 38 and 39). roundish patches which often blend. white spots caused by fatty degeneration gradually become redder. they are never present or in the outer granular layer. in diseases of the It often covers or envelops the vessels of the retina as its and so on. it is albuminuric and other origin. have a certain liril- liancv places. and so They lie mainly in the intei-granular layer and have fibt'rs. both functionally and ophthalmoscopicaliy. — This certainly the principal cause of the whit" to- spots. B. of Henle's layer. When they are superficial they are of a light blue white color and look as if they ^vere loosened up. The The granules a special predilection for Mueller's supporting vessels of the may be seen to glide over these patches. as a local piienomenon of neiii'o- retinitis of vessels. 5. retina. is 4.

changes in the vessels. as in Fig. some- may be detected on the second. Our duty the retina. In around the papilla and the region other cases the change may be located very near the papilla. so that at least an impairment of the functions remains. In still other cases such a picture may finally be produced by the increase of the changes. an atrophy of the optic papilla. the cause of the spots cannot be ascertained in this way alone. and as. such as a migration of j)igment into the atrophic retina. but rarely misleading. for the change in the retina precedes in the other symptoms many cases. was not until after the urine had been precipitated that some granular casts were found. In other cases atrophy of the papilla results from atroj)hy of the nerve fibers.ihiic)--ciipi'. 34. the decision as It to the etiology must be to the in is results of a general is examination. A case is pictured in Fig. and atrophy of the optic nerve. was caused by an occlusion of the central artery. 32 and 33.1.31 A many prolonged duration of tlic distiisc finally injures the nervous elements moi-e or less. on the other hand. tliing found on the it is first examination. although the family physician could discover no albumin it the urine in spite of repeated examinations. and. retina. 16 in which a destruction of the nerve fibers. as a result. the diseases of the fundus arc simply symptoms of general diseases. as in Figs. and that. when the consequently atrophied disk will probably show very indistinct margins. Von Michel frequently told of a case albuminuric in in which he made the diagnosis of retinitis. just as it is in make a thorough examination of the bod?/. particularli/ of the If nothing is urin£ and of the blood. with its very complicated structure and its highly developed functions. tissue Sometimes bands of connective may be seen to appear together with the advancing atrophy of the retina. with few exceptions. and yet . to is therefore imperative. as that shown in Fig. must always be borne clearly itself. 36- A description of these that is generally applicable cannot be given. Question 5 In how far can a Conclusion be Drawn from the Ophthalmoscopic Picture Concerning the Etiology of White Spots? Differential Diagnosis of White Spots from the Etiological Standpoint As final the etiology of the white spots may vary left greatly. Pigment in cells have migrated into the atrophic retina of the macula. and in cases changes are left that can he seen with the opht h. is a specially fine reagent to a great many disturbances of the general cases of hemorrhage into organism. mind that the eye not an organ standing alone by but that it a part of the entire body. It is as true of white spots as it is of hemorrhages The that they are signals of warning to show us that danger threatens.

-* sejisis we find in the fundus near the papilla. This is. miliary tuberculosis. that shown In in Fig. or yellowish and as they have been deThe picture was taken scribed under tubercle of the chorioid (page 180). not always the case. must not be taken the etiological diagnosis in make many cases from the oplithalinoscopic picture is provided that the change in the retina typical. none may perhaps be present. In many cases the hemorrhages are very large and extensive. but they do not regularly the vicinity of the vessels. from a case of miliai'v tuberculosis which j)rovetl on autopsy to be also one gray spots. and similar hemorin rhages. who has high fever and no characteristic symptoms. so the statement generally holds good. of the wiiole number of described. tliat in tlie determination of the etiology of a disease he expert can certainly retina reliance must be placed exclusively on the results of the general literally. into (a) Bedridden. unfortunatel}'. never in or near the macula. but must be stated again that. The importance of ophthalmoscopy in the difll'erential diagnosis of the above diseases has been decreased a good deal by the introduction of such specific reactions as that to tuberculin and Wiihil's. so it is only the positive condition that diagnostic. according to an outward clinical symptom. on the contrary.et The internist meningitis. even for the expert. often so as to cover the blood vessels. lie or oval white in spots. We will first di\ ide the cases. us suppose that we have been called into consultation over such a patient. or a small hemorrhage. like In tuberculous meningitis we generally find an optic neuritis. What was of tlie said above. It is self-evident that these may is sometimes be absent in sepsis. except one or two minute changes white s[)()ts. VVe will now try to ascertain it what characteristics are jieculiar to the '^dividual forms. of a severe meningitis. as thrombosis. for I examination. rejireseiited in niiliai-y we find yt'llowish. tuberculous T.V2 tlie patient died two years later with tlie syiiiptonis referalili^ to a eoil- tracted kidney. . as the same picture. What is to be expected from In us. 81tubi-rculosis. roundish. mediuni-si/ed. and sepsis can be dittereiitiated with the ophthalmoscope. In typhoid fever wo never find such white spots and rarely luinorrhages. Febrile Patients (Retinitis Septica) knows that typhoid fever.— V.

33). ordinarUi) ice sec onlij single u-hite spots of the form and size depicted in Fig. stellate figure in the it The macula (Figs. 32 and 33). when there is at the same more so as choked disk sometimes occurs r\ together with these patches of degeneration in the retina. . 30)(y) Little white spots in and about the macula (Figs. 30 ami 31. The diagnosis finally made from the general condition (see page 82). may be com- and that the same cause may give rise to the most diverse pictures. but this is by no means always present and may be met with in other diseases. 31). The beautiful picture of the stellate pgure in the Jiuieula (Fig. in the form of accompanying stripes (Fig. both striated (Fig. in Changes the blood vessels. An idea of the protean character of this disease can be obtained by combining the different forms. interruptions of the column of blood. Retinitis cilhnminuricn. These pictures are shown for the purpose of demonstrating that those things which give the characteristic appearance to one picture pletely absent in another. 20). importance. while the veins. {/^) (Figs. of the A choked disk in may the be simulated very readily an increase symptoms the optic nerve. Michel used to say humorously that he knew a certain high oflicial to be a smart fellow. on the b}' contrai-}-. 33)Changes in the vessels of the chorioid (Fig. 69)Increase of the signs on the papilla to to differentiate it (6) difficult such a degree that it is from a choked disk with patches of degeneration is (Fig. are distended. such as an optic neuritis with a large r'uiij. strengthening (Fig. (C) ('/) Detachments of the retina (Fig. the behavior of the vessels in albuminuric retinitis . 31. 34). Tile characteristic signs of an albuminuric retinitis are as follows: (a) Signs on or about the papilla.These be lacking in any given case (Fig. There are other signs they are of (t) less in addition to those that have been mentioned. 34) is so impressed on the minds of most students that iliet/ expect to find it in everi) case of tliis disease. especially its time an cedema of luatl. the arteries are much underfilled. 30 and 34). and spindle-shaped pouchings (Fig. referring to the various pictures and the accompanying text.1:53 (b) Nonfebrile Patients This comes first in 1. but these may be absolutely absent. likewise Hemorrhages. 30 and 31 )• These may also may (5) not be present. It still remains for us to consider the details of these signs. 32) and punctate (Fig. or a small white as in Figs. and ijet it is met xcith only exceptionalli/. 34) or weak- ening the individual factors. There is one point that needs to be brought out again. but diagnostic importance.

oliserved in uraniia The amaurosis and eclampsia is of cerebral origin and gives no signs in the fundus. Retinitis ciniudtit needs to be differentiated from albuminuric retinitis. A and so is the number of minute . which appear in quite like those in albuminuric retinitis and differ in only the one feature. The prognosis The prognosis very grave. about 20 per cent.134 because lu' li:ul in. Bright's dise. several processes take part time. essentially better in cases due to the nephritis of scarlet fever and of pregnancy. one that hemorrhages are generally more abundant. depends on the same pathological condition. 1). and it is in the arteriosclerotic form. Albuminuric particularly retinitis in occurs in all forms of chronic nephritis. complete recovery may take place. of l)ut is common the primary interstitial form. especially with This fact is of a certain value in making the differential diagnosis from albuminuric retinitis. Spots are seen in this disease. A stellate figure is never found in the macula and the inflammatory symptoms on the papilla are usually want- 35 furnishes a ing.'uic a tiimlv I'fcoiriiitioii of the alhiiiniiiuric cliaractLT of an optic neuritis that Irul liccn mistaken elsewhere for a choked disk. is answered in the affirmative by most writers. To what Fig 30. esjjecially when a further loss of the vision that was impaired in the first j)regnancy is to be expected in the second. good example. that they surround the cloudy region of the macula oval. met with in all these cases. The question whether an abortion is justified in an albuminuric I'etinitis due to pregnancy. is The probable length of life after the onset tlie of an albuminuric retinitis is at most two or three years in 90'/e of cases. eases of the eye. when Fig. JUid so on. transverse in P. All of these things are to he referred primarily to vascular changes. calcification and exudates. the (hcjily situated the enormous changes seen 34 are due cannot be told with certainty. there at the same fatty degeneration. in which. when the acute symptoms are not caused by an exacerbation of a chronic nephritis. degeneration. 31. some isolated. The condition is one of sclerosis of the delicate vessels of the macula. some confluent. tlie AH of the forms which were mentioned in the description of in patliohigy ri'tiiiitis. across. 2. No albumin or casts are to be found the urine. the fatty (U'<reiieration of the supporting fibers in tlie stelhite figure in particles of fat in Fig. in Fig. which consist essentially of hyaline degeneration of the small and smallest arteries and of the capillaries. The albuminuria only when it of eclampsia can give rise to an albumiiuiric i-etinitis persists after delivery.ise. Diabetic retinitis is very apt to occur along with other diabetic disiritis. Both eyes are generally is affected. The characteristic picture of albuminuric retinitis is also met with in it diabetes mellitus. We see the deg-eneration of the niTve fibers in 32. of the white spots are to he found the picture of alhuniinuric l''ig. about 3 or -i a large. and even a detached retina may become reattached.

3. when they appear in the form of isolated. which manifested itself in the form of a large central scotoma. they are more comin cancerous cachexia. The prognosis is not so bad when proper treatuR'nt is instituted. Proliferations of connective tissue are also seen to take place as a con- sequence of syphilis. indicating the presence of an axial very small. it is is in tlic nmcuhi by the direct nR-tiiod. A striking symptom is the apparently fibrinous exudates in the vicinity of and arteries elsewhere in the fundus. — In addition to the changes described on vessels. This case was one of syphilis in tiie beginning of the second stage.i. 2. Hctinitin Icucoci/thtniiica. 3. 36). die in the course of the next two or three years. silver Usually hemorrhages also are preshave white. oval. Bi'tinitis is pale. hence its prognosis is pretty bad. retinitis {)roliferans (Fig. The blood vessels themselves are very bright and consequently about the same tone of color as the rest of the fundus. or striated patches. White spots are seldom found in retinitis unwmicu. yet in the veins this particular case the vision remained very badly impaired on account of tiie the grave injury that had been done to the retina by the occlusion of artery. half of the patients. scotoma degrees. as a chorioretinitis (see (see page 179). which vary situated at the equator. . ni/phiUtica appears in i forms: 1. pages 102 and 119. 37 (retinitis proliferans). mon ent. whicii 5. we see in leucocythannia whitish gray patches with bloody margins. Leucocytha'mic splenic 4. particular case the condition seemed to be an occlusion of a cilioretinal artery.}5 bright points can be seen central scotoma neuritis. but seem to disappear suddenly as they leave the papilla. but some live ten or fifteen years with this affection. on the average. more rarely at the posterior pole. 4. WIrii a oljservtd in diabetes. in the form that is pictured in Fig. retinitis is almost always bilateral and accompanies only the and tiie myelogenic forms of the disease. 38. and hemorrhages. In its later stages diabetic retinitis frequently tends to proliferations of connective tissue. as a connection with the true retinal vessels could not be discovered. as the result of wiiich they do not stand out clearly. and are tina's an optic neuritis and such brilliant fatty spots are to be met with as are to be seen in an albuminuric retinitis. broadening and tortuosity of the in size yellow red fundus. as a rule al)out 5 degrees. and the diagnosis is then made positive by Wansermann's reaction. as a neuroretinitis page 7. as a rule. as compared with the retinitis.5). In tills This picture resembles that of a partial occlusion of the central artery. The sight of such white spots must always arouse the suspicion of syphilis. round. »\t from quite small to as large as the papilla. as in Fig. never the lymphatic. sometimes slightly elevated. in all)uiiiinurie which generally has an extent of over 10 Diabetic retinitis is usually met with only in the worst cases of (iiahctes. in a diffuse form (sec page 149).

. j'ellowish white spots retinitis. tlie In cases of choked disk. — Tlic essential features tlie of tliis condition have already' been described on 7. may sometimes be found without any true of nerve fibers (see page 80). under caption of connective tissue.13(5 6. These are usually caused by patches of degeneration in the layer Tlie knowledge of this fact is very valuable from the so-called alliuininuric in the differential diagnosis of this condition choked disk (sec page 79). pa^e I'ii). especially after condition lias lasted a long time. Retinitis proliferans.

PLATE XVII Fig. Fig. 31. 30. Retinitis Retinitis Albuminurica Albuminurica .

with or without hemon-hages. arc to be seen in the ri'gion of the niacida. fatt}' The caused by is it degeneration (see page I'JO). yellowish white spots are its to be seen below the upper temporal artery. one or two white spots. for it is met with in others. 30. such as tumor of the brain. as shown by their roundish form.vus). number of roundish. The minuric stellate figure retinitis. AVliite strijc.'5 years. Albuminurica i. which the retina.j) TIic fundus distinct reflex is wry darkly lie |ili. it is not pathognomonic of this tliscase. Retinitis (See page Albuminurica Ititi) This is bv far the more common form of albumiiuiric retinitis.Albuminuric retinitis occurs chiefly in connection ne])hritis. because of the absence of signs of inllammation upon and 138 . and liands can seen aloiiir the vessels. . that form an incomplete star. A little below these are a number of spots of blood. following fairly well along course. a very ])rominent and suggestive symj)tom of albuis but by no means always present. The changes mav indeed be much more sometimes be tri\ial and lacking in character than the ones depicted.5. and syphilis.nuiilc(l. may A large all the basis on which to make the diagnosis. a piirily incidental condition. The papilla is normal. although much hss conmionly.Fig. "itli chronic interstitial and the patients usually die Avithin 2 or . is dark spot to be seen at the lower margin of the picture degeneration in its vicinity. Retinitis (Sue i)uf. No hemorrhages and no wliite spots are usually distinct changes in the vessels can be seen.L. A number enormous number of small spot. 31. to be looked as congenital (na. Indeed. Fig. Tiie center of the star of large and an is niarketi by a heap of pigment. which completely hides the markings of the 'I'he chorioid that are to be seen distinctly in temporal portion.s are visible in the vicinity of the star. is lie in the deej)er layers of The its entire region of the macula large covered by a slight veil.

Fitr.Tab. 30. Fig. 17. . 31.

.

Fig. 33. 32.PLATE Fig. XVIII Albuminurica — Neuroretinitis Neuroretinitis Albuminurica Gravidarum with Detachment of the Retina .

If the head of the optic nerve were greatly would closely resemble one of choked disk (see page 133). and the form of the change as in the preceding case. Tiie striations sliow that the lesion lies in the layer of nerve fibers whicli radiates from the papilla. Tlic papilla very red.ind of the veins tlu' indicates a serious inflannnation of iiead of tiie optic nerve that has a compression of .'i This picture has a disproportion in the cei-taiii i-esemblaiice to the is preceding. caused The disproportion in the degree of fullness of the artei-ies . This ma}' simulate.swollen the picture tiie vessels. which shows a distinct. There is a degree of fullness of the arteries and of the veins. certain places radiating striation. just The white stripes that I accompany the vessels may be ascribed to extravasation. to the passing glance. Fig. 140 . and surroundrd hy a in white ring. about a papiliai-y diameter broad. but the clianges in vessels and the hemorrhages imiiudiately correct such an error.) Fig. The picture was complicated retina. 33. or distentinn of he })erivasculai' lymj)h spaces.'J) The morbid and its cliaii^'cs in tliis ])icturL' arc is coiiliiird wliollv is to the papilla immediate vicinity. Neuroretinitis Albuminurica Gravidarum with Detachment of the Retina ( See page 1 3. 32. as regards both the reattachment of the retina and the is life of the patient. yet no hemornot the same. tile a resemblance to lueduilated neryi' fibers. materially better when the condition is due to the nephritis of ])regnancy than when it is occasioned by other causes (see page 134).j. Neuroretinitis Albuminurica (Sec page i. in this case by the jjresence of a large de- tachment of the The prognosis. rhages are present.

Fig. IH. 32. 33.lab. If'. .

.

34. 35.PLATE XIX Fig.— Neuroretinitis Diabetica . —Very Severe Neuroretinitis Albuminurica Fig.

a r?ddish tone. Very Severe Neuroretinitis Albuminurica (See page 138) The entire vicinity of the optic nerve. for a distance of is from two to five pupilhiry diameters. some The color of these varies with whiter. Neuroretinitis Diabetica (See page IS-t) Diabetes can produce a picture that is quite similar to that caused is by nephritis because the anatomical basis of the changes is the same. A beautiful stellate figure is to be seen at the macula. its margins slightly hazy. others blended into large patches.Fig. here and there. 35. Fig. one of which so close to a vessel of the retina that the latter must be supposed to be thrombosed. The lower part their age. The arteries are small. picture was taken (see page IS-i). They become reddened and lose their sharp contour in the stage of absorption. Numerous little spots of hemorrhage can he seen in the upper part of the lies picture. the veins dilated (see tlie This patient died four weeks after page 133). 142 . transformed into a chalky white hiyer which has. Tlie papilla very red. 34. and there is a little oedema in its vicinity. the of the picture exhibits discrete. younger ones are the many yellowish white spots.

35. Fig.Tab. 34. 19. hig. .

.

36. Retinitis Proliferans in Diabetes Retinitis Proliferans in Syphilis .PLATE XX Fig. 37. Fig.

normal. Hemorrhages and wliite spots complete tiie picture.Fig. 36. tlie TIio masses of connective tissue follow the vessels.J4 ) Retinitis j)rolitVraiis not rarrlv is tlii' i-esult of a diabetic retinitis. ai-terv Along the upper temporal preceding case. Wassermann's reaction was Otherwise the fundus seen in the periphery. which originate from the sheaths of the vessels. Retinitis Proliferans in Diabetes (Sec pages I'Jit and i. but atrojihic spots may sometimes be 144 . Fig. . Some of the vessels of the retina have disappeared.37. Retinitis Proliferans in Syphilis (See pages 129 and liiS) The papilla has a peculiar. some show varicosities (see page 102). which is is characteristic of an optic neuritis that undergoing involution. red tone. just as in the This patient presented the symptoms of syphilis in the secondary stage. cold. and vein are cordlike l)\nidles of con- nective tissue. is positive. from adventitial slieaths of which they are accustomed to orifrinatc.

Tab. Fm.37. 20. .

.

Retinitis Luetica Fig. 38. The Same Case Six Weeks Later . 39.PLATE XXI Fig.

about one pa{)illary diaiiieter broad. Two months later nothing was visible except the coronula and the oblitera- tion of the vessel lying farthest to tlie left. The papilla normal. These symptoms appeared about months after syphilis had been con- Fig.j5) Attention the field is called chiefl}' to an ojiacity whicli passes transversely across is of vision. The exudate has undergone involution to a considerable extent. still is badly impaired by the persistent central scotoma. that look six can be seen on some of the tracted.Fig. such as visible in the often to macula. vessels. Retinitis Luetica (Set' page i. 38. The Same Case Six Weeks The Later vision is The central opacity has subsided considerably. The vision is was greatly iiiijjaired by tlie presence of a central scotoma. 146 . like bits of cotton. 39. and tlie is to be ascribed to an occlusion of a cilioretinal artery whicii supplies region of the macula. A is coronula. Large exudates. be seen after occlusion of the central artery. especially the veins (see page 135).

.. 21.Tab. Fig. Fig. 39. 38.

.

PLATE Fig. XXII Sympathetic Optic Neuritis and Chorioiditis Colloid Deposits on the Vitreous Lamella of the Chorioid . Fig. 40. 41.

Fig. the arteries scarcely was normal. the veins were distended. Fig. The color about them was slightly brownish. Such spots ai'e thought to be retinal by many authors. About two iiiontlis injury soiiir deposits appeared on Desceiritis. whose left eye had been lost as the result of an injury with subsetjuent iridocyclitis. These so-called very colloid deposits are thickenings of the lamina vitrea which destroy the pigment epithelium at the places where they occur. upper margins indistinct. mal. the visual field no central scotoma could be demonstrated. Sympathetic Optic Neuritis and Chorioiditis (See page 127) Tills picture was taken from after thr tlie riylit eye of a man. but there was no true pigmented edge. yet the fundus could be seen very Vision was reduced to Va the normal. which is commonly the same as that of the brighter parts lying near the papilla. moved inward a little in the picture. The spots near the papilla are brilliantly white. filled with minute. Far in the periphery. yellowish spots. and The papilla was very red. and no lump of pigment. reddish gray appearance. vwt's iiieiiibrane in the other eye. seen a The fundus is nor- The optic nerve and the vessels are likewise nor- In the region of the macula. yet the entire character of the disease indicates that they are situated in the chorioid. 148 . its changed. while those in the macula have a faded. 20 years okl. together with a slight The vitreous was well. and no distinct <edoma was visible in the retina. and the spots did not change during this time. of the tcsselated type. 41. The patient was under observation for about three years. 40. As a rule the vision is little disturbed (see page 127). mal. and in the vicinity of the papilla can be number of roundish spots with a rather strong pigmentation about them. Colloid Deposits on the Vitreous Lamella of the Chorioid (See page 127) This picture was taken from the eye of an old woman. were several sharply defined. This reddish gray is not the usual color. diffuse ojjacities.

ii'. 33. 40. Fig.Tab. n .

.

but distinctly veiled. nearly the cases that have been described in which white spots were is to be observed. The obliteration of the markings of the chois rioid is not evident because the fundus strongly pigmented. is When. DIFFUSE OPACITY OF THE RETINA (a) mthout yrcai differences of level. The vessels of the retina are simply covered by a thin veil. alone it is usually very difficult to recognize. according to degree of the cedema. the same as the white spots. ffidema plays a very important part is. and yet we are guided pretty often to this diagnosis by a fairly rapid. in is met with all it in almost all severe diseases of the retina. (Edema ple. optic neuritis or pseudoneuritis has been Besides the gray color wc see that the vessels of the retina appear to be slightly. In other cases the oedema may be considerably more marked. on the other hand. which surrounds the reddened. It most of these cases. in To it a less marked degree tliis such an oedema can be seen in Fig. so that they appear tjie to be broken in places. the most coniinon and the most important cause of . in the so-called refinifii diffusa. It is particularly well marked in in syphilitic disease of the head of tlie optic nerve. a local phenomenon of diffuse neuroretinitis. 1. 18indistinct papilla like a ring.149 III. oedema in The is diagnostic importance of determining whether a condition pointed out on page 71. (Edema is also met with in circumscribed inflammations of the chorioid When such an oedema occurs in the region of the macula (see page 125). 18 and 31i center). Tiie portion of the retina afFccted tlie appears gray. The commonest cause is oedema. and appears as a sequel to any optic neuritis. and the markings of can be seen very indistinctly. this a A'ery deceptive sign (see Figs. yet commonly cast into the background by the more prominent changes in the eye (Fig. or reddish gray. for examother. 22). 31). dent when the oedema is chorioid beneath it found in The latter characteristic is a more or less albinotic fundus is particularly evi(see Fig. the color of the fundus uniform. The pupil must then be dilated to admit of a more accurate examination. and it may have even a striated appearance when less lies chiefly in the layer of nerve fibers. or tiu v are embedded. This form is usually of a syphilitic nature. mav be due to various anatomical conditions. is is still not positive the test for central blue blindness This done best by Haitz' method. Hemorrhages and white spots are considerably it common then than Although syphilis is wlicn is due to otiicr diseases. and when the diagnosis should be made. great impairment of the vision.

its but one or more of Then the amaurosis branches (see Fig. 38. in This form is likewise met syphilis. 44) until finally the normal color of the fundus returns. are verv imi)ortant (see in oedema only may precede the changes present. 45 with Fig. and sometimes perfectly The arteries are usually. an outspoken inflammation. 'riii^ affictions of tlii' optic iutvl". P'lying "o attention to the is not total. is of diagnostic value. In these cases the optic nerve. The opacity gradually retrogresses (compare Fig. but affects only certain porthat the trunk of the artery off. page 77). The parable. form of diffuse o])acity of the retina the diffuse infiltration with white blood corpuscles. but intermixed with a gentle dark gray tone. though by no means always. In these cases the demonstration of the cherry is red spot (see also page 72). This is characterized hy the very marked sheathing of the vessels of the retina in Fig. 4. it is not the entire trunk of the artery that becomes occluded. Pulsation absent when pressure made on the eyeball (see page 107). occlusion sets in with sudden amaurosis. make themselves A necrosis of the inner layers of the retina in connection with recur- rent oedema (Figs. The opacity itself is brighter it is in these cases than white. it is in purely infiannnatory oedema. is 45 on the papilla. Considerable accumulaevident as white tions of leucocytes in circumscribed places spots. in size. It also may happen is occluded behind the point where certain branches are given The is region supplied by these branches is is then seen to be of a normal red color. The vision appertaining to this place The opacity in cases of conmiotio retina' (Fig. 43) if^ to be looked . It inav also he ohserved in choked disk. especially in riety. hemorrhages and white spots are seldom wanting such cases. due to diseases of tlie tl»e tlie ear. invisible. shown with 42. opaque. This migration of pigment is particularly distinct in the region of 16). which commonly is irre- Sometimes white spots). is Another. 44 and 45) underlies the opacity of the retina in occlu- sion of the centred arteri/. and sometimes in leucocythaMiiia.150 peripaju'lhirv a>dcma. the alhuiiiiniiric vain symptom It seems to lie in the as striations are almost never seen. it is not tlif only one. due to a migration of pigment cells into the atrophic retina ( Fig. with a uniform whiteness of the papilla and an extreme contraction of the arteries. hut usually lies in its opaejue surroundings without such a special border. as in Fig. which is to be ascribed to a distention of the adventitial sheaths of the vessels with white blood corpuscles. which sometimes surrounded by a particu- larly cloudy halo. or considerably diminished seen in is The eroded place in the vessel itself can be many cases as a w-hite spot. where it takes part in the formation of the coronula (see page 127). the macula. and may he at times deeper layers of the retina. very much rarer. while the rest of the retina j)reserved. 3. tions of the field of vision. hut 2.

The wt)rd "Hat" must be emphasized in this c(mnection. i. the macula or the papilla. is harmed little if at all. because the chief and most striking symptom in the eye when the detachment is gibbous is the difference in level. which are described as scintillations.iily i'ounil have a close resemblance to the one just described. when the detachment position it is partial the loss field is greater or less. blue is perceived by them as green or gray. balls of fire. ticular attention is to be paid in the differential diagnosis to the white cords. according to the occupies. The color of the detached portion is gray. which are visible elsewhere. 46). flashes. The etiology 1. near The condition of the vessels. When a detachment connnences the patients complain of siihjective sensa- tions of light. generally enable a ditt'erential diagnosis to be made from other forms of as opacity. person the latter may seem later it moves downward and causes a son looked at defect in the upper part of the so that the per- may seem to have no head. Objects also appear to be distorted. The transudate j)asses away 5. in the vicinity of which the vessels of the retina often show abnormal bends.i. P'lrblue. It may be is purely ocular. 47). A the absence of the markings of the chorioid in the detached portion. The vessels of the retina throughout the same area are vei-y dark and have no reflex. Ordinarily the detachment begins in the upper part of the retina and field causes a defect in the lower part of the tient looks at a of vision. or jagged ( metamorphojisia). as when the detachment caused by an injury. tumors. or circles. . hemorrhages.. taken together with the history. varies. their vision becomes disproportionately bad as the light is reduced. 151 upon as due to x-asomotor disturlxincc -idfh transudation. in a Another cause of a diffuse opacity is the flat dctachnu-nt of the retina (Fig. degree of myopia 2. These are the apices of the very valuable symj)tom is folds formed in the retina. which are normal or dilated. or local. The of vision usually exhibits a contraction that corresponds to the detached part. and sometimes they seem to be of nounced green. sparks. In many cases the diagnosis of these diseases as the cause can be determined from .. In cases of total detachment of the retina the loss of vision is very great. general. either a perforating wound. The detachetl places are blind to blue. or a high nephritis. The local elevation of tlie retina may frequently be perceived by parallactic displacement and by determination of the refraction. such hemorrhages and ruptures of the chorioid.d (Fig.. or a contusion. and the other signs of traumatism frequently to he observed. and the patients suffer from hcmeralopia.e. so that when the pato have no legs field. Usually the vision few days. sometimes gray green or gray The detachment may be total (Fig. It is The opacity mayusu. 46). '>r ])arti. as when due to or syphilis. a pro- bent. the so-called photopsias.e. . arteriosclerosis.

caused hi/ a tumor of the chorioid. into the eye with the mirror of either the inverted. 1. as sliown by the sclerotic vessels in the vicinity of the pajiilla. The reason of this phenomenon is that the detached portions of the retina lie farther forward than the rest and conse(|uently have a different refraction. while others arc indistinct. The arch- ing of the retina can be seen. tiie A visible difference of level indicated wliiii some parts of fundus are plainly during an ophthalmoscopic exaiiiinatii)n. and the portions that were indistinct become clear. on the contrary. as from sck'roscd vessels. A dark spot is to be seen when a tumor is present. changed color and the formait The papilla has a slight haziness. movement can be detected. sucii as a great amount of (I'deiiia. (b) Diffuse Opuiitii of the UctiiKi xdtli is Mdrkcd D'ltfcrcncca of Level. when introduced into the mouth. while those which were clear at first become indistinct. This method is par- ticularly useful when tumors are situated in the posterior segment of the eye- . Detachment of the retina shares this symptom with quite a number of other diseases. the detacjiment gives the impression of a solid. and 50 exhibit types of such a detachment. Figures 48. of the bulla back and forth ma}. which is increased by the fact that a reddish shimmering from the tumor beneath the detached retina can be seen in certain places. Figures 48 and 49 therefore do not give pictures tliat are true to nature of a detachment of the retina. transilluminates the globe from behind. which might perhaps cause to be mistaken for an optic neuritis (see page 72). a detachment of the retina No Its margins are sharply defined. in addition to tion of folds. Fig. The zell's difference is not so distinct as is it is in these pictures in many cases. l-'ig.' spots. and opacities in the vitreous. in contrast to the above. which. in others the differentiation whiti.be seen during movements of the Fig. and then the differential diagnosis best undertaken with the aid of Hert- lamp. they are. or the less upright image. A 2. 48 shows a (jibbous detaehment caused its hi/ an exudate. composite pictures which assume the ciianges to be made in the position of the examiner. 49 shows. while a serous eirusion allows the light to pass through freely. or black spots. firm mass. Ai'tcriosclerosis is the etiological factor in 47. as the detached portions then look much red than the When by the detached retina lies very far forward it may sometimes be seen oblifjue illumination. rather. In most cases the diagnosis of a detachment of the retina can be made more conveniently by simply casting light of the ophthalmoscope than by an examination others. 49. but it is cliaracteristic of detachiiunt of I lie lutina wluii it disappears as soon as the observer makers his examination from a greater distance than usual.152 other ocular signs. distinct movement eye. but must be made by means of a general examination.

and that the patient is In a total.153 ball.^^ j^ duce a similar picture. to the number of IT. 3. but when these means to the condition of jection. funnel-shaped detachment of retina no picture of if tlie fundus If the can be obtained. and in 50% itself is a forerunner of a sclerosis of the cerebral vessels. Of these 14 had an attack of apoplexy 1 l/o within 2 years. with heart disease. transilluniiiiiites the eyeball laterally. 50 shows a gliamu of the retina. II. disease within 2 or 3 years. Veins of the Retina. 2. the other 3 died from arteriosclerosis in from to 7 years. tlic Tlie diagnosis rests chiefly on tiie the facts that an embedding of the vessels of retina can be seen in the tumor. as can readily lens tion. tlie Thrombosis of only veins of the retina has not the It is eases of the arteries. 1. is lie understood we look at P'ig. a purely local disease in bad prognosis of the dis. . One died of apoplexy 3 years later. (a) Seventeen patients. Concerning the Prognosis as to Life of Diseases of the Retina and Chorioid Geiss I lias drawn conclusions. Fig. with arterioelisease. light into the eye with mirror of the ophthalmoscope. All of the patients observed. young. nosis not so liad. wiiich 3. suffered from an attack of apoplexy within 4 years at the Sudden Occlusion of but without heart the Central Arter//. or limitation of the projecy. Arteries of the Retina. Marked 7() Arteriosclerosis oi the Retinal Vessels. R. between 40 and 70 years of age. tion is indicative of detachment. (b) Si:: patients. correct projection of a hemorrhage. Prog- Syphilitic diseases of the retina do not have the same bad prognosis as arteriosclerotic changes. ol)ii(iue transparent the detached retina can often be seen by illumina- and the rounded protrusion can sometimes be seen by tlie simj)ly throwinti. of which the following is an abstract. wiiich may not make manifest until a long time afterward. with heart disease. sclerosis. 4 from heart and one was still alive at the end of 4 years. as a large tlie fail a conclusion as retina can bo drawn from the pro- hemorrhage into the vitreous may proLoss. (c) Nine patients. between 40 and 70 years of age. while for those in the antei-ior seginent better service is obtained from Sach's lamp. 39 years or less of age. ranging in age from 40 to most. years.50% of the cases.

.'{« Of in patiints. .i.III. 2 died from 2 yeai's. of hemorrhages of years. harbinfrcrs arteriosclerosis. V. Diabetic retinitis has a different prognosis from the isolated hemorrhages in the retina met with in diabetes. diabetes. Retinitis Diabetica. to 4^ '2!) died within 1 year: -i died in from 1 to 2 years. isolated hemorrhages macula. and the retinal hemorrhages caused by syphilis do not partake of this bad j)rognosis.s No from I\ in to tile coiulitioii of tlic vessels in the brain can he drawn sclerosis of those in the chorioid. VI. Three jiatients with retinitis albuminurica gravidarum recovered. into the brain. Retinitis Albuminurica. coiu-lusioiis . Retinal Hemorrhages and chronic ne[)hritis are. Vessels of the Chorioid. Half of cerebral apoplexy. which are to be considered as precursors Apoplexy supervened in only ^ of the cases. as a rule. . of the patients died within 2 or 3 years. which yet may not occur until after the lapse Hemorrhag'es into the vitreous in the in young persons.

XXIII Retinitis Luetica Commotio Retinae. or Berlin's Opacity .PLATE Fig. 43. 42. Fig.

be suggestive of a slight (. In the case presented here the papilla color lie is is little its almost normal. it may incline more to yellow. 43.sec impairment of the vision. entiate it its name not from first the city. disappeared completely after a few days be more intense than it page 72). \o hemorrhages are visible. its margins are slightly hazy. or Berlin's Opacity (See page l.jO) This opacity received mologist Berlin. The changes. or to white. The vessels of the retina look ha/y throughout the entire extent of the opacity and are y)artly sheathed everywhere. but from the ophthal- who was the to describe the condition. 156 . striated. are normal. were found to he tlie cause of the trouble. Commotio Retinae. which caused only a papilla is The much as to. on the contrary. Retinitis Luetica (Sec pago 150) Primary rctiiiitis. diseases of the retina due to an atteetion of the capillaries of the choiioid. A light gray ring. wiiitish spots can be partial seen. cloudy over a large extent. reddened. but the vessels. only a few. The nature of this change has not ^et been learned. together In a similar case. and circular inflammations of the adventitia and intima. and need not be situated exactly in the region of the macula. Such a lesion can be mistaken for a connnencing detachment of the retina when the vessels do not run smoothly over it and there is any sign of a fold. color of the opacity The may it is in this case. especially the veins. wlieii not a local plicnomenon of a ncuro- a fairly rare disease in comparison with the secondary syphilitic comparatively involved. Init the vessels that upon exhibit is a distinct obscuration and sheathing. and to differ- froin detachment of the retina. is sypliilitic retinitis.Fig. with a rather darker center. and only a few of the vessels of the chorioid can be seen through the opacity. 42. The retina. was studied pathologically by Buck. can be seen in the region of the niacida. which with obliterations of the capillaries. The condition depicted here was produced by the blow of a ball against the eye of a boy 12 years old: tiie picture was taken a few hours after the injury. Fig. enough so commencing optic neuritis. "it its margins are fairly distinct.

Tab. Fig. 43. Fig. 23. . 42.

.

45.PLATE XXIV Fig. the So-called Embolism Occlusion of the Central Artery in a Later Stage Fig. Sudden Total Occlusion of the Central Artery. 44. .

The arteries gradually refill through the mediation of Zinn's arterial in plexus (sec page 168). The scarcely papilla lie is very red. its margins completely hidden.58 . The oblit- erated place can be plainly seen white color of the cherr}' the lower artery on off the papilla. and Occlusion is caused by n true einhoius only in is usually due to a slowly developincr. D. which receives its combination with an oedema. The it well-known cherry red spot can be seen in In this case this is is surrounded by a white areola (see pages 72 and 119). but alwa^fs present. normal The vision remained lost in spite of the improvement in the objective symptoms. 45. which can be seen distinctly in Fig. the arteries can whitish gray and opaque. hut sudtlenly becoming total. but the retina remains incapable of performing its functions and the papilla atrophies (see Fig. fundus has passed to a considerable extent. seen. not The white color of the fundus is the consequence of a rapid necrosis of nutrition through the central artery. 16. and there are signs of the coronula. 16) Fig. closure of the lumen of the artery by a proliferation of the intima. the macula. so that the cedematous tissue in wanting and the dark color of the fovea stands out its marked contrast to surroundings. The The like red spot is no longer so conspicuous. the So-called Embolism (See l)ayt' 150) extremely rare cases. Occlusion of the Central Artery in a Later Stage of the papilla have become in part sharply defined again. and the minute branches the vicinity of the macula become strikingly prominent (Fig. across and is including both the papilla and the macula. A large area of the fundus. endarteritis proliferans. 45). 1. The margins its redness has passed away. the cerebral la3'er is The red spot brought out by the fact that is absent at the fovea. a wing to the papilla has regained approximately its An area attached color.• Fig. about 6 V. Sudden Total Occlusion of the Central Artery. The arteries have in become refilled. 44. in is the cerebral layer.

Tab. 84. . 45. 44. Fig. Fiir.

.

PLATE XXV Fig. Flat Detachment of the Retina Detachment of the Retina Fig. 47. 46. Partial Flat .

and vessels. entire picture seems quite dull. papilla is normal in every respect. if it The detachment does not extend quite to the papilla. Outward and upward shows plainly several from the papilla is a large discolored place. and then the picture would look like one of optic neuritis (see page 72). Partial Flat normal. because the vessels have no light streaks. except lie on the papilla. which On folds. Detachment of the Retina retina in its The papilla is The vicinity presents discolored islands over which the vessels pass with a distinct bend. An is artery makes a marked bend as passes over the very white band. Flat Detachment of the Retina (See page 151) TIk' level. the other side of the papilla the retina is still attached and allows the markings of the chorioid to be seen distinctly through sclerosed. over which the vessels of the retina deviate from their courses. The in vessels many The such as are scarcely to be seen it any other condition. as regards its color. 47. Fig. tortuosities. margins. but detachment of the retina. The retinal vessels have no light streaks.Fig. for did the mar- gins of the latter would be obscured. 160 . flat This is a picture of an almost total. 46. as almost always the case in detachment. its The little fuiulus lias. Some of these vessels are make no mistake if we diagnose this as an arteriosclerotic rttina. so we will detachment of the in the portions that it. instead of normal reddish color. a green gray appearhave ance with bright and dark bands here and there. Naturally the vision is badly impaired.

47. Fig. 46. .Tab. Fig. as.

.

49.PLATE XXVI Fig. Large Gibbous Detachment of the Retina of the Fig. 48. Detachment of the Retina Caused by a Tumor Chorioid .

and. his head. white bands. The surface is smooth. nephritis. The vessels of the retina are in part accompanied by broad. turn. on tiie other hand. No fiuctuatinff movement could be seen when the head was moved. yet it presents The line of demarcation of the detached certain characteristic differences. tensely stretched.Fig. 49. 162 . Detachment of the Retina Caused by a Tumor of the Chorioid (See page 15'2) This is also a composite picture. Wlicn he focusses on the papilla the detached portion of the retina will be obscured. Although certain places the reddish color of the the retina over it. The margins of poral side is the papilla are not (juite sharply defined. the region of the papilla becomes indistinct. are due to an existing The detached elevations. When the eye was transilluminated with tumor can be seen shining through HcrtzdVs lamp the region of the detachment appeared as a dark shadow. The detached portion was clear on transillumination with HirtzdV. On its tem- a distinct conus. 48. Fig. shows depressions and and exhibits distinct These are to be ascribed to the fluctuations of the wavy movements whenever the patient fluid moves accumulated behind the retina. when he leans backward in order to see distinctly the detached portion. it has a certain resemblance to the preceding. wiiicli depicts wliat the observer may see at varying distances from the eye of the patient.s lamp. in which have been jiroduced by transudates that. retina protrudes very far forward. Large Gibbous Detachment of the Retina (See page 152) This is a composite picture. and in portion is (juite sharp.

I'm.Tab. -IS. . 4't. 1 1-. 26.

.

Small Glioma of the Retina . 50.PLATE XXVII Fig.

uncommon.e. as the tumor frequently appears in both eyes. in jMay. and then tlie proliferation advanced very rapidly.id anv etiolr)gical connection with the papilla are epi- tumor could not be determined. The bright zone about the The liemorrhages near tlie tumor shows that the pigment thelium of the retina is also involved. Tiie overlaid by The is similarity of the picture to the preceding ones is very great. until nearly the entire space of the vitreous has heen filled hy it so as to produce the so-called amaurotic cat's eye. the tumor was as large as an apple and protruded from the orbit.. 50. It is therefore in reality about as large as a pea. lie in the tissue of the tumor of tile At : the upper pole of the tumor may be seen several black spots and one large patch of atrophy. it occasionally happens to those who habitually examine both eyes with the ophthalmoscope that they are able to see a glioma of the size here depicted. i. in December. which indicate a simultaneous disease chorioid whether or not this h.Fig. hecause glioma occurs in earlj and is not noticed in most cases. and measures Sl^X^J^L) D. This picture was taken in January. it broke through the eyeball. 1910. on account of tlie iihsenci' of sul)jective comphiints. by October it had filled the entire vitreous. 1911.. 5ViX6% mm. so that at the time of the death of the child. Small Glioma of the Retina (See page 153) childiiood Such a picture as this is rarely to he seen. 164 . tumor apparently starts from the vicinity of the papilla. in ]March the tumor was as large as a bean. But. which is !'• it. but it to be noticed that some of the vessels of the retina itself. 1912.

Tab. 27. 50. Fig. .

.

Chorioid .

.

each into two branches. The short posterior arteries branch very quickly after they have passed through the sclera and the lamina suprachorioidea. S) through The space between the two mem(Su). the this is lamina vitrea. the lamina vasculosa. which enter the eyeball near the optic nerve. at the place where passes over into the ora serrata. but must be mentioned on account of ciliary vessels. (see Finally comes 5. Then comes Next is 2. first The anterior ciliary arteries run in the four recti muscles. branes. before they reach the limbus. the layer of the larger in the is 3. which of the greatest importance pathology of the diseases of the chorioid and the retina. tic fibers. from 0. for it consists essentially of vessels whicli furnish nutrition to the macula and the outer layers of the retina. is mm about the posterior pole.i in this place page 111). The short posterior ciliar}' arteries likewise form a circulus arteriosus in 167 . but before doing so they give off recurrent branches which unite with the capillaries of the short posterior arteries. cells elas- hut no vessels. many pigment vessels. This lamina contains is known and as the perichorioidal space. which they supply. and 2 long posterior ciliary arteries. and divide. the layer of pigment epithelium.2 It 1.Chorioid Preliminary Remarks on the The chorioid is Anatomy rightly named. Adjoining 4. also called the lamina elastica and the lamina basalis. which demonstrable only under pathological conditions.05 or 0. On account of the great abundance of blood vessels the thickness of this varies in proportion to the degree to which they are filled. to 0. The long posterior arteries pass without branching in the layer of large iridis vessels to the ciliary body. and 4 anterior. -t its intimate pathological relations to the chorioid. membrane it and varies also in different places.1 or 0. the layer of capillaries. and form the main part of the arteries of the chorioid. 54. The vascular supply is through the so-called which come from the ophthalmic artery. which enter near the limbus.08 mm. the lamina suprachorioidea is very loosely connected with the sclera (Fig. where they empty into the circulus arteriosus together with the anterior ciliary arteries. which appertains to the retin. the choriocapillaris. They consist of from to 6 short.

54. as its veins carry away not only tlu' blood from the chorioid but also that from the ciliary body and the iris. but this it indirect connection with the nutrition of the globe is of practical value. In rare cases they end at the posterior pole (Fig. according to the arterial supply. it This connection of but little practical im- portance because is never happens that a central artery of the retina which central j)()rti(>n is obstructed in its sufficiently supplied with blood throuf. tlu' anterior from this point to is transition into the ciliary body. The venous outflow of the chorioid is quite different from its arterial itself.uhI forms a coiiiicction between Tiiis is tlie ciliary optic'i.-h this means. The fibers. The iridis anterior ciliary arteries arc of importance to the chorioid only in so far as they unite with the long posterior. and hereditary syphilis. General Diagnosis of Diseases of the Chorioid. Krueckmann in Axcnfcld's text-book. which therefore The former form the sup])lied by the short posterior jirincipal its source of the nutrition of the chorioid. chorioid contains besides vessels many collagenous fibrils and elastic as well as a great (juantity of cliiomatophores laden with pigment. They connnonly pass from the chorioid into the sclera behind the etjuator of the eye in the form of from i to 6 large vessels. the posterior and lai-(^er of which extends from the its into the region of the eijuator. as when the retrobulbar space has been exenterated the removal of a tumor. which comes only through the terminal filaments of the short posterior. principally in eyes that are higlily myopic. with the exception of the choriocapillaris. and the retinal vessels. ciliary arteries. and of the recurrent branches of the long posterior arteries. while the second receives blood throufrji the recurrent branches of the long posterior ciliary arteries. as in chorioretinitis pigmentosa. The equatorial portion has the poorest supply. or the main one to be affected when degenerative processes take place in the eye. tion is It is therefore not an accident that this por- the first. is. C'onse(iuently they are far more numerous than the arteries and have many more anastomoses. The latter are to be found in all of the layers of the chorioid. The ])apilla chorioid may be divided into two very uneciual portions. wliic'li surrouiuls the papilla . so far as They are Caused by Diseases of the Vessels The schematic drawing. and naturall}' of the lamina vitrea.168 the scli'Di. for able to preserve the latter when all of the posterior arteries have been in divided. and thert'by with the short posterior is arteries. known as the ciriniliis artei-iosus iiervi is or the circle of Zlnn. but especially in the spaces between the vessels. supply. The pictures in the circles show typical changes that are to the same as that used by be ol)seryed . with r material changes. through the eirculus arteriosus ciliai'y major. 3). Fig.

This laid bare. because of the pigment III. tlie choriocapillaris lias been destroyed. or at least its layer no*: The latter in tiiis example perfectly uniform and trans- parent. reveals at once a resem- blance to tiie distiirhanees here delineated schematically. as in II. The still vessel B on the otiier liand in a normal I\ . for exception of Number in tliis I must be understood of course. Picture is I shows oplithalmoscopically a perfectly normal condition. A glance !it the succeeding plates. and as these lie one behind another they give oplithalmoscopically the impression of a dark. suprachorioidea V the layer of large vessels. Here. . because. I. as has been said repeatedly. shows the way which tlie black spots are brought about. except to be changed in with tiie Number \'l. The process has extended fartiier. This presents a further advanced stage. whicli arc not schematic. II. all The retina is absent from all.16!) in diseases of the vessels of the cliorioid. 74. the outer layers of the retina receive their nutrition from tlie cliorioid. The cliorioid has almost wliollv disa])peared tiaces only of the intrain vascular pigment can be seen. so that the cliorioid cannot be seen. lies between them. Tlicy appear to be of a normal color and they are found to be normal under the microscope. the vessel The vessels still of the cliorioid are almost totally obliterated D alone contains a slender column of blood within \. In picture II the pigment epithelium tlie is destroyed to a considerable it extent as result of disease of tlie subjacent choriocapillaris.i pigment so that with the glia tissue. (C). The pigment epithelium and the choriocapillaris iiave coiiiplettly disappeared. its thickened walls. anil disturbances the vessels of tiiis membrane nmst naturally manifest themselves tiirough nutritive derangements of the corre- sponding portions of the retina. brought about by tju' likiiding of the processes of the MitclU-r'. normal microscopically. In consequence of the break- down of tiiat this layer the larger vessels of the cliorioid can be seen in the form of a relatively bright network on a dark backgrouiul. E tlie pigment epitlielium of the is retina. of basal cells. black spot. Ch the choriocapillaris L the lamina vitrea. at Fig. if is made homogeneous. which likewise . ing one may use such an expression. but at the same time iiave in bands of tissue have been formt'd wiiit'ii their spaces newly formed pigment cells. Su the lamina . is When in these traces of pigment disappear the pure white sclera VI. As there is no pigment the places formerly occupied by the chorioidal vessels the spaces formed by their absence have their forms and courses. . Further. condition. the picture shows the secondin diseases ary pigmentation of the retina that appears This cells is of the chorioid. especially with supporting cells. also are obliterated Portions of the larger vessels in tiie (A) (a). for example. and conse(]uently appear ophthalmoscopic is picture as white cords. Near each cliange is presented the corresponding microscopical picture. S indicates the sclera .

of Fig. 2. lesion. depigmentations tin as uril. ]Vliiit learn from these schematie pictures btit in that not onhi abnormal as pigmentations. also It is solf-o\ idcnt that fornud pigment epithelium can 7CC proliferate into the degenerated chorioid. that the markings of the chorioid can he seen. there vessels that is may be ijrought about by a congenital In such cases. ment can migrate into the retina only when the lamina vitrea has been injured. tiie two jilaces The pigment is laijer of tlw retina. 41) association witii pigmentations of the retina. central. A guide to the etiology is fre(iuently to be found in other ocular symptoms. Hut it must he remembered that similar however. partial or total abscnci' of this pigment layer. The following proposition is particularly applicable to him: // black or white spots are present in the fundus a thorough examination must be made of the organism. parencliymatous opacities are found. The pigment of the ehorioid. lu ncc ill it is that colloid deposits can fretjuently be seen on this lamina (Fig. as in albinism. Almost all diseases of the chorioid are sijmjitomatic of general diseases. zehich is not to he confined to the ordinary physical and chemical in which the tuberculin and Wassermann tests are to be made. and ])icturcs thus caused to atrophy. yd the etiology must be determined mainly by This is particularly true for the general practitioner. if the cornea is investigated with the binocular loupe methods (done. is indi- cated in all such cases. for example. color. l''ig. just the same as in Although certain con- clusions can be drawn in a number of cases from the position. wiiieh covers the chorioid It is and limits viiw with the ophthalmoscope. but may not perceive or interpret the nu'nuter dift'erences. is none of the abnormal heaping of pigment and disease of the Compare the periphery to be seen in every pathological case. but and tleeply situated vessels. which indicate a past interstitial keratitis and may persist for years after the subsidence of such an inflammation. or fine. wc have obtained an almost . who can sec the black s])ots with the ophthalmoscope. 57 "ith 8. size. on account of his lack of special practice. only when tiie nutrition of this is layer impaired by a disease of the ehoriocapillaris. is may in he empliasi/ed again that pigment to be seen normally in the fundus 1. Pigpigment takes place at the same time 7cherever pigment is destrot/ed. whicli lies in the spaces between the vessels of this membrane and may last very long in spite of serious chorioidal The general statement may be made that an abnormal heajiing of disease. Therefore a very thorough general craniination retinitis. are to he looheil upon signs of disease of It clmrioid. and appearance of the such an examination. with the exception of those that are due to traumatism and some conditions that are congenital. Etiology of Cliorioiditis.: 170 the brown frraniilcs of neuli) fiisciii pcnetnifc into the retina.

171 positive proof of the syphilitic origin of the disease. but these are usually associated with a sinmltaneous disease of the iris and ciliary body. arteriosclerosis. the lesions in the chorioid are not to be seen with the ophthahnoscope as sideration in this place. in In a small number of cases the ilisease the chorioid is of a metastatic pysemic nature. and. The if following conclusion can be in the vessels. because usually of sy])hilitic origin in yoinig persons. tire drawn from the ophthalmoseojjic picture we look for changes // sclerosed vessels is present in the chorioid the probable cause of the if disease cither st/phiUs. Dots of pigment in tlie pupils of iritis. or nephritis. as tiiese ordinarily induce a great opacity of the refractive media. Consequently they do not come into con- . a rule. young persons. whicli are to he considered as traces of a iritis is bygone point toward the same etiology. is no such vessels arc present the probabje cause tuberculosis.

DIAGNOSIS A. as in Fig. bone corpuscle form. which often appears 172 as a circle (Fig. is the branchings of the vessels of the chorioid are most extensive in the region of the equator and the movement of the blood at this place normally rather slow. (b) lumpy form. the sort of pigmentation. the differences of level. whether changes are present in the vessels or not. the form of the change in the chorioid. It may perhaps seem rather forced and schematic to classify changes it in is the chorioid according to the position they occupy in the fundus. 1. as has been mentioned capillaries to have will already. 5. . but very often have to rely upon the general exam- we are quite frequently able to do so by the observation of the following points 1.: . :?. or depigmentation 3. The Sort of Pigmentation and Depigmentation. yet tlic ctiolo<ry from the oplithalnioscopic con- dition alone in all cases. The Position file of the Lesions in Chorioid. With regard (rt) to the form of the pigmentation we differentiate a regular. so if we imagine a general contraction of the to taken place through a hj'aline degeneration of their walls. for the spot appears in this or that place in accordance with certain pathological reasons. but not. we the first and most prominent symptoms Hence we differentiate between expect appear just at this place. General Diagnosis After the diagnosis of a disease of the chorioid has been made the following points need to be taken into account in order to establish its etiology: the position of the lesions in the chorioid. 2. Although we cannot duduce ination. disseminated distribution. a 51. 53) . the region of the equator (6) the region of the macula. («) the periphery of the fundus. (f) {(1) the region of the papilla. 4. For example.

When this pigment disappears also in leaves a pure white surface. are indicative of transverse gunshot wounds of the orbit. characteristic picture (Fig. ordinarily give a beautiful. ((/) (<•) 57) . in In many be cases changes the vessels cannot be seen. depigmentation irregular. pigment. as in Fig. if we can of the find sclerosed vessels in other parts of the fundus. (/. 57)- Another example: When the vessels of the chorioid sclerose and gradually become destroyed. Finally the aid of parallactic displacement must be sought in the exam- ination. and lie concentrically to the margin Their margins are sharply cut and frequently covered with of the papilla. at the posterior pole of the eye. Are Changes Present in the Vessels or Not? Vascular changes. The forms of some changes are so characteristic that we can deduce from them at once some conclusions as to their etiology. In such In rare cases the ruptures are situated more peripherally. because depressions and elevations from the ordinary level are met . meet with the following typical forms of depigmentation: a diffuse depigmentation. For example: Diseases of the lead to in dccolorizations of the pigment epithelium. especially of the large vessels. Tl)e Form Change. that of the sclera. to be considered as due not to contrecoup. and cases the lesion eff'ect is ai-e not concentric to the papilla. elevated. jiignientation along the vessels of the retina (I'ig. The retinal vessels pass smoothly over them. Among these are: (a) Ruptures of the chorioid after contusions. chorioretinitis prolifcrans. In most cases they lie to the outer side of the papilla. consequently we are justified the conclusion that there is a disease of the choriocapillaris whenever we see such depigmentations with the ophthalmoscope (see Fig. as inougli snuff had been sprinkled over the fundus (Fig. 64). brilliant white patches. (b) a depigmentation (f) (f/) S. but to the direct of the injury. in medium-sized spots. 5. These are white. Differences of Lerel. but their presence choriocapillaris may inferred. we can often recognize the positions they formerly occupied from the fact that the pigment lying between Circle them outlines their margins. 79. In spite of the fact that the vessels can ascribing these white spots to vascular no longer be seen we are justified changes 4. more rarely to its nasal side. 57). at the place where the blow was received. 55. usually crescentic. chiefly in We (rt) found in the periphery (Fig. 63). strewn richly with pigment. as in it V of Fig. an irregular form. as in Fig. 54.) Large. the form of minute spots.173 (c) a powder form.

but the functional field disturbance in the periphery shown by a contraction of the visual and the onset of a marked hemeralopia. of the macula. but is characterized by the presence of little white spots. but is destitute of ])igment. some of which caused by injuries. become visible in consequence of the atrophy of the pigment layer. or. a better name for the disease. peculiar. as depicted on the plate. brought about by the fact that the pigment follows along the branching course of the smaller arteries and the capillaries of the retina. and of the optic nerve. Note: As the retina is Special Diagnosis always secondarily involved is in diseases of the chorioid the term ciiorioretinitis preferable to chorioiditis. (a) Changes in the Chorioid and Retina Which Occur Chiefly or Exclusively in the Periphery We consider will first begin witii these because they are the most common. some by general diseases. Fig. and oblit- erated vessels can often be seen distinctly. pigment atrophy of the retina. First ill''- wu iiavc to tliinlv of proiifi. and will the diseases tliat are characterized by Collections of Pigment 1. The markings of the chorioid pigment. Collections of pigment that resemble bone corpuscles are found in choriorciinitis pigmentosa. and usually has a yellowish hue (see page 52). and may in be rather lum[)y. or tracery. has a similar etiology. The vessels of the retina are greatly contracted. leaden color. Diff'. which is is suggestive of the microscopic appearance of bone corpuscles. may be more or less abundant." and tumors of the chorioid. at the first glance. but it gradually' becomes more abundant as the disease progresses toward the macula. \ot infrequently even the large arteries may be seen to have mantles of At first the pigment is only sparsely present. which causes similar subjective symptoms. B. may be more delicate their The form. 51 shows these collections in their characteristic form. in the so-called "stapiiyloiua verum. is known as retinitis pigmentosa sine ])igmento.riitions of connective tissue. Retinitis punctata albescens. is The disease congenital and usually occurs in children whose parents .^ivnces of level can also he detectt'd in in colohoina of tiie chorioid. The entire fundus acquires a from which the disease can frequently be recognized The papilla is atrophic in advanced cases.Mi with. They are of a deep black color. The central vision may remain good is for a long time. A form of chorioretinitis is also to be met with which exhibits the same This subjective sj'mptoms as pigment atrophy.

When they are due to hereditary syphilis the former existence of an interstitial keratitis can frequently be proved either history. cases in wliich suggested in are rather common. A second form of pigmentation of tlie periphery of the fundus by is masses of pigment. Such a fundus is shown colloid deposits in Fig. This pigmentation is by no means as regular and as shown in Fig. only in severe cases that they extend as far as the papilla. 75. in Fig. in the such as are seen in Fig. 41. Depigmenfation the Periphery. syphilis of the eye. is present here in tlie form of very minute These produce salt it is points. pe^ipher}^ Thev are They are caused by either hereditary or acquired syphilis. often confined to circumscribed portions of the periphery (see Fig. but only to those that are typical. which exhibits collections of pigment of a similar shape as the consequence of a plainly demonstrable sclerosis of the vessels of the chorioid. The pigment are little." Although this is fairly rare in a distinct form. and are to be found It is chiefly in the periphery. bright spots the pepper and salt fundus. such as diseases often met with in company with other . iicre No attention will be jiaid to such depigmentations as occur acci- dentally in the periphery. which are described on page 127. tlie The retina and the optic nerve This is is one type. shown 63. In many cases the spots may be mistaken for on the vitreous lamella. an appearance that has given rise to the name "pepper and fundus. and depicted in Fig. between which roundisii depigmentations. of hereditary other characterized by the so-called Snuff fundus. as rule. They are due to hereditary syphilis and are signs of that disease. the secondary pigmentations are usually of a less regular form 52 )i but (compare is with Fig. it is usually found only at certain places in the periphery. 4. tiie in which the little may be more muiieroiis than dots of jiigment. are likewise found usually surrounded by a bright halo. are not as seriously involved. Isolated spots of pigment. This fact differentiates it from chorioretinitis pigmentosa secundaria. 1. or by the by finding blood in vessels situated deeply in the tissue of the cornea. like those shown in Fig. Tlie changes are to be seen most frequently the lower periphery of the eye. the grosser. 80. not as delicate as that seen in chorioretinitis pigmentosa. 2. Discrete Depigmentations. wliilu colloid deposits first appear in old age. 67). 53. but they are rather larger. xchich are often unnidar. 3. 55.175 are nearly related. in These are met with round. They are a to be seen in childhood.

involve the region of the macula under certain conditions. which are usually found only of the extent and intensity depicted in Fig. A wvy had casu of tliis nature is shown vessels. unless they happen to be situated the center of the macula. as shown in Fig. ari' likewise often is due to hereditary syphilis. may be stated here that in the beginning of a disease of the macula the region of the latter reflex ring about it is abolished. which Aside from these relatively insignificant changes in infrequently associated with arc not a development of connective tissue.-uul piyiiR'iitat i()n>. is proposed to deal in this place only with the typical diseases of the peculiarities. tliffuse changes may 80. or a 59 to 62. (b) Changes The but it in the in Chorioid in the Region of the Macula the chorioid. ill wliicli tlu' ntina is involved tlirough destniction of its and the ()|>tic nerve is atropiiie. but rarely happens. scleroses are to be found in the large vessels. yellowish. 2. yet it is to old age. the macula. that such lesions of the retina as oedema and hemorrhages are lacking (see the nasal side of the papilla in Fig. is This often called senile degeneration. 56. 64. 69)- . even tlun they are most marked retina the periphery. 57. ment. in which the and optic nerve were involved as well as the chorioid. for premature arteriosclerosis sionall}^ the may occur in by no means confined young persons occaintensity of same as senile cataract. although they are invisible the central j)ortion. Superficial Dcpigmcntdt'toiis. Such an arteriosclerosis can be simulated. may spread more or less over the fundus in in exceptional cases. it in rare cases. Arteriosclerotic Changes in the Macula. 8. perhaps with abnormal touches of piglittle bright. in such cases.176 of the in Fi<j. The varying types and The markings of the chorioid stand out with vuiusual distinctness. The peripheral part of the fundus hrightencd and in the large vessels of the chorioid can be seen. such changes are depicted in Figs. These depigmentations. vt'ssi'ls . by the smallness of the arteries of the retina and the presence of detached spots of pigment. or reddish yellow points may be seen with Colloid more or less abundant proliferation of pigment between them. such as is shown in Fig. and that the 1. ivnd The changes are very trivial in cause no symptoms at all. by a nephritic disease of the vessels of the chorioid. but Fig. This can lie distinguished from a partial albinism. 58 is a picture of such a case. deposits are sometimes found in their vicinity. as shown in Fig. It macula that are characterized by certain appears to be slightly hazy. which will be desci-ibed lati'r. as tlie result of thi' destruction of thi' chorioeapillaris.

verticallv. Aside from the possibility of an innnediate extension tiie staphyloma to the region of macula in cases of high myopia. (c) The Changes in the Chorioid about the Optic Nerve. Tlie So-called is Coloboma of the Macula. it does not seem best to devote a picture to tiiem.. D. running near the entrance toward of the tiie macula. The Changes r. myopia are to be ascribed to the eft'tct of the stretching exerted upon the vessels of the chorioid.s arranged in rows or formed into a network. and usually present a network of its same. the form of a ring. has an tlie edge of pigment. 71). 3. often irregular. or a dirty gray. or several smaller ones of the same nature. or b/j the Presence of a Foreign Body in the Eye resemble closely those that have just been described. and upon the tissue of both this These changes in memlu'ane and tlie retina. have been dealt with for the most part on page 33. have been mentioned on page 37. and jieripapillary atrophy of the vessels. extend out from tlie margins of the staphyloma. the region of the macula. spaces are found in the layer of pigment epithe- and at the same time small heaps of pigment. tlie place of the macula may be occupied by a single white. or short bright stripes. Its comparatively regular margins differentiate this from other spots in the it is chorioid. sharply defined large spot (Fig. takes the place of the macula. D.Changes in the Macula Cauxid by Contusions. with which frequently associated. In other cases a hemorrhage.sh band. which measures 3 P. or a deep black spot of pigment. in the Macula Caused by High Myopia have been thus described by Michel: little brigiit "Sometimes lium. the halo. which sometimes causes ruptures and apertures lamina. such as the conus. In many cases whiti. bordered by a more or less broad. which are joined in the region of the macula l)y transverse lines (Fig. or yellowish points may be visible near one another. in the temporal portion of tlie posterior segmenb in the elastic of the globe. . frequently in The changes that take place on the papilla. or greenish little elevation. 4. horizontally by from large size and to 3 P. or lines. is and it sometimes happens that a thrombosed vein of the of the optic chorioid to be seen. 72). when hemorrhages in may be present nerve and the vicinity. as well as the shadows ef the so-called stapjiyloma verum (Fig."' fringclike edge of pigment. as well as disease of the chorioidal vessels. and because it is quite seldom that they are to l)e seen. not edged with pigment. the staphyloma. For tliis reason. or transversely oval spot 1 in This a roundish.177 2 . 73).

irregular heaps of pigment appear at the same time. which run smoothly over the white surface. The prognosis of sclerosis of the vessels of tlie chorioid is by no means as bad as that of sclero. 67). lie tlie chorioid behiw tlie })a]jilla.i In addition to the vessels of the retina. More or less abundant. only in the region of the macula tiiat a place can be seen which. Arteriosclerosis affects two regions. and sometimes some brownish ])laces can be seen. Frequently it is met with in com- . is A and special tinting valleys.sis of those of the retina (see page 1. the latter may sometimes be is perfectly normal. The vessels of the retina may. on the contrary. in many cases it is situated quite peripherally and can be seen only when the patient looks far downward. 83). branches of the ciliary vessels that pierce the sclera can usually be seen . due to a faulty closure of the fetal ocular cleft. 84 and 85). the coloboni. and may spread from this place over the entire fundus (Fig. Such an extensive vascular sclerosis may be cau. some of them in is containing . The greater diameter always vertical. black in edge of pigment. The size of the coloboma varies. 84). or may not be involved in the sclerosis. The extent of a coloboma does not necessarily accord with a correspondfield ing defect in the of vision . Tliis is true also of the typical Coloboma Colobomata of is of the Chorioid (Figs.slender columns the schematic drawing in Fig. 68 portrays a case of this nature tlie in which the It is vessels of tiie chorioid were sclerotic over almost entire fundus. 54. still optic nerve.'53). and that of the entrance of In Fig. and it may extend above the disk and involve the macula (Fig. 85). blood. these are often twisted like corkscrews. Fig. with which a gray blue tone often mixed. given by irregular excavations which form cases the coloboma is little hills In many bordered by a sharply defined. is still capable of performing functions. is The color is a brilliant white. and have the form of an egg. Tiiis resemble those shown form of atrophy of the chorioid which commonly progressive.sed by hereditary syphilis in exceptional cases. 65 may he seen plainly of sclerosed large vessels. A coloboma is to be considered as a true arrest of development. this depends on the extent to which the retina involved. in the inverted image above. Ruptures of the Chorioid are characteristically situate'! about tlie entrance of tlie optic nerve (see page 12(5 and Fig.178 Peripapillary Sclerosis of the Vessels may be nientiontd afraiii. tliat of the tlie macula. in oth( rs it begins just below the papilla (Fig. or of a shield. and flecks of pigment can often be seen itself. although its changes are present.

for a pigmentation characterisin tic of a chorioiditic spot is almost never lacking cither the spot itself. is wavy. Those that are •without visible changes in the vessels.ses is covered partly or wholly by the oedema. and in many ca. cicatricial. ami nystafrimis. connective tissue in the place of the membrane that has been desti-oyed. this indicative of The color may be j^ellowish. An ophtiialiiioseo|)ie picture wiiich is is seldom seen is of the optic nerve. Atrophic spots are divided 1. and sclerotic vessels of the chorioid. 78). But syphilitic diseases of the chorioid very often manifest themselves from the start through a sclerosis of its vessels With regard (compare with the schematic drawings in Fig. little if any larger than the papilla. such as colohonia straliisimis. see page 126. choi'ioid are present. Fresh spots are small. They can be perceived most readily when a vessel of the retina happens to pass over them (see the vein running downward and inward vessel is in Fig. rarely elongated. either The white color is brought about by the sclera shining through the atro[)hic chorioid. The spots them- cannot be seen. or vertically oval hollow. have to try to draw conclusions from that the spot chorioiditic clear at once in most cases and not retinitic. and when the diagnostic signs mentioned on j^age 170. is Tuberculosis the principal cause in cases that belong to the first group. The latter dis- particularly to be suspected when they lie in the anterior segment of the chorioid. 54)to the differential diagnosis from spots having a similar apin a pearance. or the depends on whether portions of the mem- brane has been completely destroyed. yellowish graj'. Old atrophic spots are found great variety of forms. deep vessels and central opacities of the cornea. These spots The Disseminated Form of may be fresh or old. so that a weak pigmentation tuberculosis. or by the forma- tion of a hyaline. into an atrophic one can be watched It is comparatively We is usually see the picture produced by the bygone process and it. the raised at such a place. These spots are usually caused bv tuberculosis or ease is syphilis. wiiich are usually situated at the posterior pole of the eyeball. or pure white. roundish. Syphilitic spots are usually nnich more abundantly is pigmented than the tuberculosis. (d) The papilla doubled in size known as coloboma and appears as a roundish. i:ito two varieties: 2. dots of pigment on the lens. of tlic iris. as well as of other parts of the body. in The develop- ment of a fresh spot few cases. are present. gray. or in its immediate vicinity. micropiitiiahiios. Chorioretinitis is characterized by the fact that it appi'ars in multiple spots. Those that are Kith visible changes in the vessels. .179 pany witli othor inalforinations of the eye. and about a quarter of the size of the papilla selves when they are not confluent. the accompanying a?dcma of the retina alone is visible.

74) almost The jngmcnt usually other places. frequently con- and have festooned margins. The vessels of the retina are intact ami. heaps of pigment. they are bordered by a distinct. are rather fuller than usual. and more or less abundant masses of pigment. 74 we find that The essential points regarding the the schematic di-awing resembles actuality very closely. in It was he also who pointed out the diagnostic importance of the changes vessels. which vary in size and number. as of such details may find give rise to the greatest variety of may be seen in Figs.sck'rosi. which looks like the decoloration produced by a chemical substance. Such a sharp pigment edge as never seen. Usually. The spots are usually roundish.s. as though the nodule of the pigment epithelium. Under 76 and 77. as is shown in Figs. yet not innnethe spot has in its diatelv connected with the sjiots. 52). is observed lies in syphilis (Fig. At most in its center a little dot of pigment. Visilile ('liaiificft in the One was had to retinitis. tlie of the most important services rendered to the world by call v. and totally atrojjhic places h brought about by the confiuence of separate spots. The number.180 while svpliilii^. appearance and origin of such diseases of the chorioid as are produced by changes in the vessels have been described with the aid of schematic drawings. tinent. The pigmentation connnonly in is is slight. sometimes only a single fundus. Michel attention to tul)erculosis as one of the main causes of choriothis Altliollfi'ii idea met it at first with the stron^rest opposition. sonutimes great numbers are scattered over the entii-e Fresh spots may be present along with old ones. 78 79. and form of these spots vary a great deal. he all satisfaction of seeing adopted by almost leave to ophthalmologists. iirtcTio. the Although we <d' nnist generally is the final determination of the etiologv a disseminated ciiorioidit tiie general examination. Atrophic Spots Wittioiit Vt'sacls. growth had lifted up a little piece The combination pictures. Alropliic Spots in tlic iritli Changes Vessels. In rare cases the spot is covered l)y a network of pigment that resembles in its form chorioretinitis pigmentosa (Fig. accidentally discovered in an ophthalmoscopic examination. In their vicinity is often to be found a depigmentation of the pigment epithelium. is The number one is of the spots extremely variable. are also present. certain circumstances a quite diffuse arrangement of changes in the vessels of the chorioid. 1. . yet the differential points mentioneil do good service. black ring. size. when the lesion does not spread diffusely. 2. When we look at Fig. and iRphritis must be taken into account in those that belong to the second. near by. in many cases.

or malaria. Very little pigment found neigh- borhood. 1. showing eitlier a hollow or an elevation. in Sometimes we arc surprised to find that the vision spite of the extensive changes in the fundus. or a tuberculous nature. ment of the macula. often they are due to diabetes. comparatively good The ordinary changes level. but life. Detachment of the is chorioid. aljsolute is the patients have metamorphopsia. covered witli In benign cases the nodules are transformed into connective tissue. The noninjiamiiKitorii tumors. forates the sclera and proliferates into the tissues of the orbit. make themselves manifest through the accompanying detachment of tlie retina and liave been described in connection witii this condition. difference of level is balanced by a compensating proYet in a number of tliese diseases a can be detected by means of parallactic displacement and may be produced reverse. both circumscribed and total. and in many cases verum (Fig. 73). in the chorioid generally cause no differences of as a defect that liferation of tissue. and detaclmicnt of sarcoma and metastatic carcinoma of the chorioid. conglomerate tubercle. matory. Chorioid with Differences of Level..181 Syphilis. at objects seem to be distorted. have cleared up under suitable treatment only a harmless atrophic spot is usuall}' to be seen at the affected place. Tuberculous inflavimation. may greatly resemble It often pera gumma at first. The conglol)ate tubercle near the head of the optic nerve gitis may threaten life through the production of a menin- by proliferation along the sheath of the optic nerve. rendering exenteration of that cavity necessary. . arteriosclerosis less is and nephritis are tlie cliief causes in these cases. which gives the impression of a mountain snow by is Its bright color in its and its elevations and depressions. A hollow is found cliiefly in colobomata of the In the latter it is cliorioid (see Fig. and the the observation of bends in the course of a vessel. occurs. Hence a general examination always necessary. 85). and often render After they an exact diagnosis impossible by an opacity in the vitreous. Inflcnmnatory tumors are of cither a syphilitic. of jiigh myopia. either inflammatory or noninrianicliorioid. to The former. but its result is commonly not so benign. it is it rarely diagnosed during observed more often in pathological preparations.e. gummata. which extend far into tlie start with very severe signs of neighboring tissues. Changes in the. such as see page 152. later central relative and scotomata appear. known as a stapiiyloma An elevation in is observed in tlie tumors. 2. are accustomed inflammation. The degree to wliich the vision first is disturbed depends mainly on the involvei.

but perceptible marking's of bulbi. thereby ruptured together in man}" the The excessive cicatrization set up in healing. such as are observed losis. is The way in which this is brought about is that the eyeball pressed in from behind by the explosive force of the shot passis ing rapidly through the orbit. \Vheii it is particularly large it appears as a light brown protrusion. are relatively frequent. elevated spots associated with an extremely rich development of pigment. gives the characteristic picture.182 It appears as a dark surface with parallactic displacement of the vessels tiie cliorioid (compare with detaciimcnt of the retina. in arteriosclerosis. and after extraction of cataract. with the production of white. Chorioretinitis proliferans forms a typical picture after transverse shot wounds of the orbit. . and the chorioid places. Elevations due to the jjroViferatioJi of connective tissue in the chorioid. with organization of the hemorrhage. such as occur in high nij'opia and . Total detachment takes place in phthisis of the retina. It is observed most often witli iuiiiorrhages into the perichorioidal space. chorioretinitis proliferans.ifter wounds. tubercu- and especially after wounds. in congenital buphthalmos. page 152).

51. 52. Secondary Retinitis Pigmentosa .PLATE XXVIII Fig. Retinitis Pigmentosa. or Pigment Degeneration of the Retina Fig.

so this one differs from only in degree. and a functional disturbance. Such a correct diagnosis at once. with exception secondary retinitis pigmentosa. which have produced an atrophy that resembles a staphyloma. because the pigmentation follows the capilIt also follows the larger vessels. similarly sclerosed vessels may also be seen in an area that lies far in the periphery. Such a condition is shown in this picture. Tiiat Secondary Retinitis Pigmentosa pigmentosa in form of is retinitis which the disease of the vessels of the chorioid particulai-ly marked it is designated by this term. described are characteristic. But it is customary also to in call a condition "secondary retinitis tosa" which no way corresponds in etiology. This area is covered by a network of "bone corpuscles.50 years old. and the fundus has a blue gray tone. although the shape of the deposits of pigment same. 51. is to the typical form. condition may be seen in this picture in thi' vicinity of the papilla. which may suggest the The vessels of the retina are quite drawn out and of very small caliber. it often affects children of consanguineous Fig. in The papilla is of a waxy yellow- marked cases. They resemble form the micro- scopic picture of bone corpuscles. these vessels are met with in the typical form of the disease. Retinitis Pigmentosa. who had arteriosclerosis." A similar network can also be seen at a place where the sclerosed vessels are not so plainly visible. but name the siioiild be applied only of to a certain distinctive clinical picture. as Changes in was mentioned pigmenthe above. or state of the papilla. or Pigment Degeneration of the Retina (Sec l)agv 17-i) Tlic tvro is apt to call cxciv (liscasu of the fundus associated with tliis colii'C tions of pitriiient retinitis pigmentosa. tiie be low. which was taken from the eye of a woman . extent. can be seen distinctly . the so-called hemeralopia. 57)- Other characteristics are the color of the papilla and the color of the fundus. The predisposition to the disease ])a rents. in the vicinity of the papilla The changed vessels of the chorioid. ISi .Fig. congenital. Tin lie form in uiid position of the spots of pigment They papilla. Among of the field the subjective symptoms are an extreme concentric contraction is of vision. the outermost periphery and in advance frradually toward laries of the retina. 52. In most cases an involvement of the chorioid is shown by the presence of sclerosed vessels and depigmented places. which sometimes have mantles of pigment (see also Fig.

.Tab. 88. Fig. 52.

.

PLATE XXIX Fig. Grossly Pigmented Fundus of Hereditary Syphilis . 53.

sometimes to be seen throughout the entire periphery. Grossly Pigmented Fundus of Hereditary Syphilis (See page I To) In contrast with the preceding pictures tlie pigment is seen in this one to be in large. A depigmented also to be seen about the pajtiiia. round masses.Fig. in eyes a condition that iiiti is met with rather frequently It is that have suffered from rst itial keratitis. in other places the pigment has blended into an blaclc ])oints. The This papilla and the vessels of is tlie retina are normal. 186 . whicii have a distinctly circular form in the places where inextricable it is less dense. 53. sometimes to be found only in separate circumscribed areas. network of The detached groups tlie of spots are separated by a zone of depigme!ited tissue from zone is normal.

Fig. . 29. 53.Tab.

.

Schematic Pictures of Diseases of the Chorioidal Vessels . 54.PLATE XXX Fig.

54. Schematic Pictures of Diseases of the Chorioidal Vessels (For the explanation of this plate see page 168) 188 .Fig.

54.r Chorioid - Fiu.Tab. =»-- ' _ -_-• <^. QsaaaaacsfiaflDD <2 '•> o"^ ^ ^^^ft^':^ -^^^-^^^ %^l:.::fe ... !• Retina . 30.

/ .

Very Severe Chorioretinitis Due to Hereditary with Atrophy of the Optic Nerve Syphilis. . 56.PLATE XXXI Fig. The So-called Pepper and Salt Fundus of Hereditary Syphilis Fig. 55.

which arc often sur- rounded by lialos of denser pigment. 190 . completely. in This boy had suffered from an attack of syphilitic meningitis childhood. Fig. which caused an optic neuritis with a subsequent atrophy. must be supposed to be of inflammatory oi'igin in spite of the sharp margins. 55. The most of the papilla. striking feature is the almo. This picture was taken from the eye of a hoy years old. On account of the total absence of an excavation the atrophy fairly and the invisibility of the meshes of the lamina cribrosa. of which onlv very small. The So-called Pepper and Salt Fundus of Hereditary Syphilis (Sec page 175) The it papilla and tlie vessels in ol' the ri'tina are normal. other. and at the same time the serious disease of the vessels of the retina and chorioid asserted itself. The vision of this eye naturally was nil.'J Syphilis. The characteristic feature in this fundus the presence of mnnerous little. Sharp margins are rather frequently found in cases of niuritic atroj)hy that develop iluring childhood. in which few details are visible. with the exception of a few dots of pigment and some bright spots that rest of the faintly remind one of the depigmentations si^en in the preceding picture. The density "f the In some ))laces pigment epitluiiinn varies hides the chorioid ditt'erent in parts of the fundus. Near the papilla can be seen some sclerosed vessels of the clioi-ioid. roundish depigmentations.Fig.s the markings of the latter is arc plainly visible. Very Severe Chorioretinitis Due to Hereditary with Atrophy of the Optic Nerve l. sclerosed traces can be seen in the innnediate vicinity The papilla itself is perfectly white. The fundus is of a dirty gray color. A j)atch of distinctly sclerosed vessels to be seen in the is vicinity of the optic nerve. 56.st total absence of retinal vessels. early Some of the vessels of the chorioid are also visible in the uppermost })art.

I'ig. 56. 55. .. 31.Tab. Fig.

.

57.PLATE XXXII Fig. Chorioretinitis Due to Hereditary Syphilis .

192 . Only a few spots of pigment surrounded by bright the periphery. because the pigment epithelium and the choriocapillaris have been destroyed (sec page 176). The arteries of the retina are very small.Fig. Some of the veins of the retina have well marked mantles of pigment in their peripheral portions. areola* can be seen in The markings This is of the chorioid can be seen very plainly in the periphery. especially in its temporal half. 57. Chorioretinitis Due to Hereditary Syphilis tlie Tliis picture presents anotlier type of hereditary syphilis of eye. The papilla is rather paler than normal.

32. .Tab.

.

PLATE XXXIII Fig. 58. with Atrophy of the Optic Nerve . Chorioretinitis Due to Hereditary Syphilis.

entire funilus shows a iiigh degree of depigmentation. Chorioretinitis Due to Hereditary Syphilis. 56. which is surrounded b_v a very distinct ring of glia tissue. Hh' condition here presented was preceded by a meningitis. It whicli call to mind cannot lie determined with certainty whether the crescentic reddish spot a hemorrhage. with the remains foci. 194 . of the {)ignient grouped about separate roundish Fig. with Atrophy of the Optic Nerve As in tln' case depicted in Fig. because in the macuLa is many of the small spots of pigment exhibit a reddish tone of color. or a deposit of pigment. 58. The The vessels of the retina arc very small and drawn out. 55.Fig. a consequence of which was tlio atropliy of the papilhi.

5S.Tab. .. 3»- Fig.

.

60. 62. Fig. 61. Senile Degeneration of the Macula Senile Degeneration of the Macula Senile Degeneration of the Macula . Early Stage of Arteriosclerosis of the Vessels of the Chorioid in the Region of the Macula Fig. 59. Fig.PLATE XXXIV Fig.

Fig. but grosser than those seen is white band that too broad to must be su])posed to be a senile The pigmented halo. The papilla is surrounded by a It to. otherwise the fundus is normal. it in the too white. bright points are to be seen lying gramiles. Senile Degeneration of the (See page 17()) Macula In this case also some large vessels of the chorioid arc visible. ])aj)illa is in this picture. in A The fact a bed of pigment Some areas too red of depigmentation are visible picture. 62. vision in this case was y^ of the normal. edge is likewise broader than the physiological pigment ring. some of the can be sien plainly place is the macula.Fig. the rionnally colored large vessels of the chorioid have become The The white spots are due to colloid deposits on the viti'eous lamella. and tliat consi'([uen( ly visible. spots. Vision was reduced to ^sThe {)igment epithelium of tl-.e retina and the ciloriocapillaris must have been destroved. Senile Degeneration of the Macula (See })age 17()) Another form of degeneration in the macula is shown number of very minute. Early Stage of Arteriosclerosis of the Vessels of the Chorioid in the Region of the Macula (S(v \mgv lT(i) In this picture. circle of The fundus is otherwise normal. 'I'lie surrounded hy a very minute bright Tile explanation of this picture is that a portion of the pigment epithe- lium has !)een caused to atro[)hy by a disease of the ciloriocapillaris. with a number of fine points of pigment mar them. Fig. 61. Fig. The spot of pigment a portion of the pigment ring and denotes nothing pathological. 60. and must be be a physiological connective tissue ring. for otherwise the markings of the chorioid could not be seen. 59. considered to be jiathological. 196 . taken from vessels of the chorioid tlic eye of a man in fiO years old. although its color is not quite right for this condition. Senile Degeneration of the (Sec page 176) Macula in The changes in this picture arc similar Fig. and the conus is is in the peri()hery. 61. should in be rather yellow.

Tab.

:H.

Fig. 59.

rig. 60.

i

]".

61

hig. 02.

PLATE XXXV
Fig. 63.

Finely Pigmented Fundus of Hereditary Syphilis, the
So-called Snuff

Fundus
Region

Fig. 64.

Sclerosis of the Vessels of the Chorioid in the

of the Macula

Fig. 63.

Finely Pigmented Fundus of Hereditary Syphilis, the
So-called SnufF

Fundus

(See page 175)
Tliis

is

till'

siiiifl'

fundus,

:\.

(iiK'ly

pigiuriilrd

tv])c

wliicli

is

met with
in

in

liei-editarv svpiiilis, in addition to the grossly pitiincnti'd

one shown

Fig. 53.
is

Such a typical and
Tlu'

distinctive picture as
less

the one depicted lierc
is

seen

comparatively rarely, but a
papilla

pronounced form

mot with very often.
lesions,

and retina arc intact, the chorioid alone presents
i)c

which

ai'e

seen with the microscope to
tiie

a disease of

tiie

choriocapillaris with

secondary disturhancis of

pigment, and manifest themselvi^s ophthalmo-

scopicalij as finely granular heaps of pigment and round foci of degeneration.

Fig. 64.

Sclerosis of the Vessels of the Chorioid in the

Region

of the

Macula

(Sec page 178)

This could also be called a
depicted
Figs.
is

senile

degeneration of the macula

if

we were

not accustomed to designate by this term sucii insignificant changes as those
in

59

to

62.
visil)le in

The fundus

of the tessellated type, so tiiat the vessels of the chorioid,

with the deposits of pigment between tiiem, are plainly
of the thinness of the ])igment ej)ithelium.

consequence

The

vessels of the chorioid in the

region of the macula are sclerosed,
'I'lie

i.e.,

their wails have

become thickened. cokunn of blood
is

thickening of the walls
visible in

is

so great in places that a

no longer

some of the

vessels, while only a slender

column can be

seen in the center of others.

The The

papilla

is

normal, the retinal arteries are rather small.
is

reduction of vision

naturally very great in such cases;

in this

case

the patient could only count fingers at 2 meters.

198

Tab.

35.

Fie.

f>3.

Fig. 64.

PLATE XXXVI
Fig. 65. Fig. 66.

Peripapillary Sclerosis of the Vessels of the Chorioid

Peripheral Patch of Sclerosis of the Vessels of the

Chorioid

is The reason why they seem to be present still is that the pigment which normally situated between them If this remains visible after they have disappeared. 200 . 65. as well as that of the macula. Fig. The lumps of pigment on the margin are due to proliferations of pigment. is a favorite place for sclerosis to attack the vessels of the chorioid. formed vessels renders it very probable that this condition was one of inflam- matory origin (see page 104). the vessels ])artly In several places may tie seen to he wholly obliterated.Fig. Peripapillary Sclerosis of the Vessels of the Chorioid (See pages 39 and 178) Tlie vicinity of the papilla. The vessels themstill and invisible. while in others they are only filled with blood. and outline the empty spaces pigment also should disapj)ear a uniform white surface would be left. The presence of newly left by them (comjiare with Plate XXX). Peripheral Patch of Sclerosis of the Vessels of the Chorioid This might be mistaken at selves are wholly obliterated first glance for a coloboma of the ciiorioid if the intervascular spaces could not be seen so plainly. 66.

Fisi. tiO.Tab. 3«. 65. f-i". .

.

and Less of Those of the Retina Fig.PLATE XXXVII Fig. 67. Great Sclerosis of the Vessels of the Chorioid. Extreme Sclerosis of the Vessels of the Chorioid . 68.

Fig. and only a few of thuiii contain slender colunnis of blood. 202 . The is region of the macula shows a trace of pigment epithelium. The pigment The epitheliinn in must have been destro^'ed very extensively. This case was met with in a girl 13 years of age who had hereditary syphilis. ^(i of the normal.iler is in harmony with such a destruction. served throughout more extensive in this case. hut the visual field was concentrically contracted to an extremely small trace. and Less of Those of the Retina (Sec page ISO) All of the vessels of the cliorioiil that arc \isii)l(' are sclerosed. particularly the arteries. . vet this also the vessels of the retina are normal. Extreme Sclerosis of the Vessels of the Chorioid (See page 176) The sclerosis is greater intensity. The papilla and This vision was comparatively good. in this one it is so atrophic that the time seems to he not far distant will when the entire fundus he transformed into a white surface. the heaping up of pigment various places ]).55).Fig. are evidently contracted (see page 98). 67. 68. papilla is rather than normal (see page and the vcssejs of the retina. Great Sclerosis of the Vessels of the Chorioid. changed. and has reached a nmch While the intervascular pigment of the chorioid was prestill its normal extent in the jireceding case. Her sister had a similar condition.

OS. f-'ig. . 37.Tab.

.

69. Chorioretinitis Albuminurica .PLATE XXXVIII Fig.

which are pretty rare. 204 . in this patient was reduced to counting fingers at 2 meters. vessels. 69. The retina shows plain signs of oedema by the haziness of its is and contains some hemorrhages.Fig. Chorioretinitis (See page Albuminurica lli'S) A picture similar to the preceding one may be produced by renal disease. it The vision greatly impaired in such a case. In the present case the nasal side of the papilla is distinctly hazy. the signs of inflammation on the papilla and in the retina can scarcely be missed. In such cases.

Tab. Fig. . 38. 6Q.

.

Sclerosed Vessels of the Chorioid . Change Macula in the Fig. Temporal Staphyloma. 71. High Myopia. High Myopia. 70. Circular Staphyloma.PLATE XXXIX Fig.

Temporal Staphyloma. The punctate markings are due to traces of chorioidal pigment that have been situated altogether on tions l)etween the left after destruction of the vessels of the chorioid (see page 37). which its temporal side. pale fundus. the other farther away. 70. Circular Staphyloma. all the other details have been destroyed. and is surrounded by a circular staphyloma. which of white cords with of a tree. sclerosed ones of the chorioid. one situated near the papilla. High Myopia. in wiiich piimtatc markings can be seen. by others as fissures in the pigment is a Fig. staphyin loma. which are explained by of the chorioid. the nasal side of which some traces of chorioidal pigment and one normal chorioidal vessel can be seen.Fig. In the region of the macula some as sclerosed vessels epithelium (see page 37).'J7 in the imd 177) in The tinct papilla. which is it vertically oval this case. Change Macula (Seepages . 71. The latter is divided into 2 portions. in this case was 12 diopters. as well as some chorioidal hemorrhages to the nasal side of the papilla.'38 for the relaform of the papilla and that of the staphyloma. High Myopia. which is pure white. The vessels of the chorioid can be seen plainly in this very pale fundus. The papilla is normal. stretched vessels of the retina. shows a peculiar maze processes that remind one of the frosted branches Some dots of pigment and some rather superficial depigmentations are also to be seen. Sclerosed Vessels of the Chorioid (See pages 37 and 177) This picture presents all of the characteristics of a myopic eye. See page . 206 . is seems to blend at this place with the staphyloma. little is rather richly pigmented. or a part of them are due to fissures in the The myopia pigment epithelium (see page 37). well in the pale fundus. maze of white cords. It cannot be told with certainty whether all of the white cords are sclerosed vessels of the chorioid. has a strikingly indis- temporal margin. rest of the chorioidal vessels can be seen very The The region of the macula.

i\ . 70. -ig. :J9.Tab. Fig.

.

High Myopia with Circular Staphyloma and a Very Great Change in the Macula High Myopia with a So-called Staphyloma Verum Fig.PLATE XL Fig. 72. . 73.

High Myopia with Circular Staphyloma and a Very Great Change in the Macula (Sec pages . kidney-shaptd spot. Part of the vessels of the ehorioid are very clearly visible and some converge toward the papilla (compare with Fig. The region of the macula occu])ied by in a large. a preliminary stage of a greater change the macula. which may perhaps illusion. page 38 concerning the form of the Parallel to the nasal margin of the papilla are to be seen one large and two small gray. 72. veins indi- cate a threatened detachment of the retina. partly because of an optical are very tortuous. and soiiir of the vessels of the ehoriold can he in seen (jiiitt' plainly. High Myopia with a So-called Staphyloma Verum See })age 2() The papilla appears to be remarkably small. measuring liilus 2X21/^ papillary diameters. it is Throughout its area the fundus is considerably elsewhere. The arteries are drawn out.) Fig. ^ —2 ( D cyl. the an unusual symptom in myopia. In the region of the macula these vessels are distinctly in sclerosed in places. partly because of the stretching. because of the great stretching of the pigment The vessels are extremely small. 73. curved lines. an optical (see tliat illusion caused by the high degree of myopia staphyloma. the of which is a spot as large as the papilla. as often ha])])(iis myopia. or rcdtlish gray. surrounded by a more or spots less strongly pigmented zone. brighter than epithelium. and consequently this has been termed staphyloma verum. in the region of which the vessels of the retina plainly bend. This is hecaiise of the stretching of the layer of pigment epithelium. spot.s The papilla is surrounded A very broadest upward and outwaid. 208 . for example. black spots. by a circular staphyloma which re\eals is The vessel. sclerectasia. 3). It is surrounded by a circular is the vicinity of the papilla pouched out staphyloma). uhicli is the last trace of the ehorioid that has vuidergone atropiiy. intermixed with white and of their color. in Fig. of the retina arc ehoi-ioidal careful examination some remains of pigment. lie to both the temporal and the nasal sides of this principal The vision correcting glass. Above and below the latter lie several smaller spots of pigment. which indicates rather luiiformly (see page 17).'57 aiul 182) Tlu' I'uiulus is Vfi'V pale. composed of numerous dots of pigment. They are shadows cast by the margins of the protrusion of the posterior pole. such as may be seen. The myqpia in this case was ap])roximately 35 diopters. Fig. which are to be distinguished from the remaining chorioidal pigment by the intensity Sclerosed yessels of the ehorioid. extremely drawn out and are smaller than normal. The staphyloma is Some small atrophic is may be seen to its nasal side. 71. — in 1(5 this casi- was counting fingers at 2 meters with the U sph.

Fi". .Tab. 72. t^iii. 73. 40.

.

Neuritic Atrophy of the Optic Nerve. 75. 74.PLATE XLI Fig. Atrophic Spot the Periphery in . Atrophic Spots in the Chorioid with Plainly Sclerosed Vessels Fig.

ir])ly circumscribod spots of atrophy arc to be seen in. Atrophic Spot the Periphery in The atrophy retina of the papilla is shown to be neuritic by the indistinct marsurroundings. The absence part of the fundus than the lower. XXX for the pathology. one the other beh)w tiic macuhi. Atrophic Spots in the Chorioid with Plainly Sclerosed Vessels (See page 180) Two . in the absence Syphilis was the cause in this case. between which traces of the pigment can still be seen. but otherwise the rest of fundus is normal. so it is to be expected that the spot will be perfect!}' white within a short time. as sclerosed vessels are noticed in the fundus we have to think chiefly of arteriosclerosis. where a whitisli spot is with sharp outlines stands out amid normal surroundings. It is bordered by a beautiful ring of pigment. less It formed from more or See Plate sclerosed vessels of the chorioid. in an otlier- wise normal fundus. Two of the vessels still contain blood. The lower one resembles very closely one of the schematic drawings on Plate XXX. Scler- osed chorioidal vessels are to be seen with some pigment between them. liut the others are completely sclerosed. for a choked disk preceded the atrophy orbital portion of the optic retinal vessels is noticeable. or nephritis as the cause. is due to the same cause as the lower. syphilis. Fig. as the sclera will then be laid bare. 74. and that the case was a This corresponds to the actual conditions. except for a peculiar change to be seen in the extreme periphery. very severe one of neuroretinitis. 75. As soon of niyoj)ia. gins and the great haziness of its The latter indicates that the was involved to quite a considerable degree. which forms a mass so shaped as to divide the spot into ! smaller ones. exhibits an abundant development of pigment. The pigment epithelium has begun to become The spot is bordered by a The upper spot. which ring of pigment.Fig. The lesion in this case was due to a quite circumscribed syphilitic disease of the vessels. Neuritic Atrophy of the Optic Nerve.sli. hut the latter has begun to disappear. in and was caused by a gumma of the of any sheathing of the The pigment epithelium is denser in the upper nerve. lighter in its neighborhood. 210 . so that the markings of the chorioid tlie arc not as clearly visible above.

Tab. 41.

Fit:.

74.

•ig.

(3.

PLATE
Fig. 76.

XLII

Extensive So-called Chorioretinitis Disseminata with
Scleroses of the Vessels of the Chorioid

Fig. 77.

So-called Chorioretinitis Disseminata with Scleroses of

the Vessels of the Chorioid

Fig.

76.

Extensive So-called Chorioretinitis Disseminata with
Scleroses of the Vessels of the Chorioid

The fundus shows
it is

serious changes througliout its entire extent, so fur us

depicted here, partly by jiatches of ilecoloratioii, partly by heaps of

pigment.
I'he

papilla

and the

vessels of the

retina

are normal; the latter pass

smoothly over the
chorioid
vessels.

lesions,

hence the inner layers of the retina are likewise
lie

normal, and the lesions must
;

in

the outer layers of the retina and in the

they are changes in the pigment epithelium and scleroses of the

The
vessels
in

larger part of the fundus to the nasal side of the jiapilla approaches

the normal, yet, even in this part, lumps of pigment and sheathings of the

can be seen.

Not a normal
;

vessel of the chorioid

is

visible

any longer
filled

the rest of the fundus

above there are some vessels that are

with

blood, but even these are sheathed.

Where

the pigment epithelium between

them has already been
epithelium of the retina
of the sclera

lost

pure white places are to be seen, produced by

the sclera covered with remnants of tissue.
is

A

disappearance of the pigment
in

the

first

requirement

order that these details
it

may become

visible,

but when the pigment leaves
that resemble this one.

settles else-

where and gives

rise to pictures

Of the three causes

of disseminated chorioretinitis with vascular sclerosis, syphilis, arteriosclerosis

and nephritis, the

first

was the agent

in this case.

Fig. 77.

So-called Chorioretinitis Disseminata with Scleroses of

the Vessels of the Chorioid
This picture exhibits changes that are quite similar to those shown
preceding one, so much so that a separate description
is

in

the

not needed (see

page 182).

The symptoms appregnancy and became much worse during the second. As the second eye was seriously affected in a third pregnancy premature labor was induced, after which both the albuminuria and the changes in the eye retrogressed. When the patient became pregnant
in this

The cause

case was a nephritis gravidarum.
first

peared chiefly

in

one eye during the

a fourth time an abortion was induced at once.

212

Tab.

42.

Fig. 76.

Fig. 77.

PLATE
Fig. 78.

XLIII

Chorioretinitis Tuberculosa

they make themselves manifest bv tlio the effect they produce on the retina. for islands of retinal oedema. The oedematous places are also a hazy. 314 . as well as the loss of the light streak in the depressions. fresh tubercles The cannot be seen. old in others. part by accumulations of pigment. Chorioretinitis Tuberculosa (See page 181^ This picture sliows that is tlie typical condition of a tuberculosis of the chorioid fresh in some places. is An im})ortant point to be noted that no vascular changes are to be seen in the picture. It little. circumscribed spots are can be perceived that these are raised wherever a vessel of the retina passes over one. 78. the vessel exhibits a wavy course little at that place. The wreathlike appearance is produced by the confluence of various individual foci.Fig. characteristic of changes of level. Part of the older places are marked by depigmentations.

4». . 78. Fig.Tab.

.

79. Chorioretinitis Tuberculosa .PLATE XLIV Fig.

the vicinity of these spots is to be seen a depigmentation that looks "as though a chemical fluid had been poured over them. almost In without exception.Fig. The hritrht spots arc. produced by the confluence of individual tubercles." the vicinity is The heaping of pigment in considerably less than in diseases of the chorioid that accominto the retina as pany it sclerosis of the vessels. 216 . Chorioretinitis Tuberculosa (See page 181) Tliis picture is one of an old tuberculosis. liecomes atrophic The vessels Pigment gradually migrates (compare with Plate XXX). of the retina and the papilla are normal. 79.

. n-. 79.Tab. 44.

PLATE XLV
Fig. 80.

Healed Inflammatory (Tuberculous?) Spot Macula

In the

Fig. 81.

Fundus

of the

Eye

in

Acute Miliary Tuberculosis

Fig. 80.

Healed Inflammatory (Tuberculous?) Spot

in the

Macula
(Sec page 181)

An

inflammatory spot about twice as largo as the papilla
Its etiology
sypiiilis.

liad

formed

in

the macula of a girl 14 years old.

no signs of accjuired or lurcditary
tive, the

]V<ix.\iriii(iiin\s

was obscure, but there were test proved nega-

tuberculin reaction on the contrary was ])ositive.

The a'dema

of the

retina disappeared under tre;itment witli tuberculin, and the condition was
left

which

is

shown
is

in

the picture.

.\

white spot smaller than the papilla

is

to be seen, surrounded

by a dark

ring,

and then by a lighter one

in

which the

pigmentation

In the neighborhood of the spot are three heaps of pigment of various shapes, but on the whole roundish, each surrounded by a.
less.

brighter ring.

Fig. 81.

Fundus

of the

Eye

in

Acute Miliary Tuberculosis

(See pages 129 and 132)

The margins
an optic
colored fundus
;

of the papilla are very ha/y,

tiie

\eins are dilated, signs of

neuritis.

Three light gray spots are to be seen in the uniformly one round and with sharply defined edges, the others elonwing on each
side.

gated and with indistinct margins. The elongated spots have roundish, brighter
nuclei, with a faded

The bright

spots are tubercles

in tlie

chorioid, or, rather, patches of a'dema in the retina that the tubercles excite

by their presence.
Tubercles are particularly apt to
lie

at the posterior pole of the eye,
is

are almost always associated with an optic neuritis, which
meningitis.

and caused by a

This picture

is

from the eye of a boy 7 years

old,

who

died of tuberculosis

two days after

it

was taken.

218

Tab.

45.

Fig. 80.

1-ig.

SI.

PLATE XLVI
Fig. 82.

Extensive Rupture of the Chorioid with Development
of Connective Tissue in Places
Fig. 83.

Rupture of the Chorioid

Fig. 82.

Extensive Rupture of the Chorioid with Development of Connective Tissue in Places
(See page 182)

This patient liad received a blow on
spots could
seen at the place where
witli

tiie

eye from a broken

belt.

After

the innnciise hemorrhage into the vitreous liad been absorbed two hirge white
l)c

t!ie

injury was roci'ived.
to
tiie

One was a
and the
left.

rupture of the cliorioid

two points jutting
in tlie

riglit

Traces of some

vessels

can be seen
this

rupture.

The

entire place has an

edge of pigment.

While the color of
bluish.

spot

is

a light yellow, that of the other
in

is

rather
its

Dots of pigment are abundant, both

vicinity.

A

distinct parallactic

movement

I'ould

and in be produced by moving
the spot
itself

the.

lens held in front of the ophthalmoscope.
is

Close to this spot a smaller one

to be seen.

Both of these spots are to be regarded as pure

ru])tures of the chorioid,

while the one between them shows distinct signs of a proliferation of connective tissue, which must be considered as a process of healing.

These ruptures of the chorioid at the place of impact are seen more rarely than the indirect rupture shown
in the

next picture.

Fig. 83.

Rupture of the Chorioid

(See pages 120 and 178)

A

white crescent can bo seen 21/2 ^- D. from the papilla, to the margin
it is

of which

parallel.

The

retinal vessels pass
its

smoothly over

its

upper part,

but make
of a

a

little

bend as they pass over
reddish spot, which

lower portion, perhaps on account
tissue.

commencing development of connective
is

In the middle of the

crescent

a

little

may

be either a hemorrhage, or a tuft

of vessels.

Its

margins are distinctly pigmented.

Such ruptures of the chorioid, which often leave the retina intact, as it is more clastic, are the consequences of severe blows on the anterior part of the eye. In this case the cause was a blow with a billiard cue.

The

effect

on the vision varies according to the degree of injury to the
If the latter lies
if

retina and the position of the rupture.

between the papilla

and the macula,
hardly affected.

if

the

retina

is

torn, or

the

rupture extends directly
In other cases
it

through the macula, vision

will

be badly impaired.

is

220

83. . 4«.Tab. Fig.

.

Extensive Coloboma of the Chorioid . 85. 84.PLATE XLVII Fig. Coloboma of the Chorioid Fig.

Coloboma of the Chorioid (See page 178) Above tlie papilla in the inverted image. over which the vessels of tiie retina pass smoothly. are to be seen several bright stripes which are large. slate interpreted as folds." granules of pigment are scattered over the coloboma. twisted like corkscrews. so that scleral vessels are very is The numerous. rest of the fundus is of an albinotic character and so contrasts with those of the preceding cases. The papilla and its surroundings are normal. Such colobomata are congenital and are not progressive. Extensive Coloboma of the Chorioid stopped at some distance from The coloboma. picture farther in. therefore in reality below. a so-called "sclerectasia. Within the surface. 85. 84. one above the entrance of the optic nerve. Fig. some- times a defect found that corresponds to this place. on the extent to which the retina in the visual field is enliven the The vision depends is involved. In the middle of the coloboma shift over its center a roundish spot. extends in this area. It has a broad edge of pigment. Some scleral vessels. Some The Hence there is at this place a depression. is a gray surface which has on one side a rather brownish tone. 222 . the disk lies in its whicli in the preceding case the papilla. the margins of which lens held in front of the when the observer moves the eye.Fig.

47.Tab. Sd. 84. Fig. . Fig.

.

PLATE
Fig. 86.

XLVIII

Normal Fundus of a Rabbit

Fig. 86.

Normal Fundus of a Rabbit

Tlie papilla is transversely oval and is plainly excavated, or surrounded by a wall over which the vessels of the retina rise. To the right and left of the papilla are two enormous white wings of medullated nerve fibers in

which the vessels of the retina course.

The

rest of the fundus

is

uniformly colored.

THE COPYRIGHTS OF THIS BOOK, IN ALL ENGLISH-SPEAKING COUNTRIES, ARE OWNED BY REBMAN COMPANY, NEW YORK

224

Tab.

48.

Fio;.

86.

Index
Abscess of the brain,
extradural, 77, 90
orbit, 81 Accessory sinuses,
7-2,

78

Barlow's disease, chorioidal hemorrhages, 119
Berlin's opacity, 156

Bisulphide of carbon, 59

changes

in,

7,

79

Blooci, diseases of,

119

dilatation of veins

and

arteries, 100

Blue blindness, 149, 151
Brain, abscess, 72, 77, 81 choked disk, 81 tumors, 64, 81, 94, 101

neuritis, 59, 7i, 78, 79

Accommodation, paresis of, 7(i Accompanying white stripes, see Chorioid, 57
Albinism, partial, 39, 48, 177 Albinotic fundus, -25, 30 Albuminuria, 72, 79, 88, 118, 13-1, 170 changes in the vessels, 100, 118, \22, 2\2 detachment, 151 neuroretinitis, 130 retinal hemorrhage, 119, i22 Alcohol, 59, 79, 99 Ampliobia, 39 Anemia, retinal hemorrhages, 118, 119 retinal vessels, 102 retinitis, 135

B right's

disease, see

Albuminuria

Bu]ihthalmos, 182

Cachexia, cancerous, 119 Cataract, operation, detachment of chorioid, 181 Central artery, see Artcrv, central Cherry red spot, 73, 119, 150, 158

Chiasm, gumma, 53
Chlorosis, 82, 102, 119

Choked

disk,

15, 24, 79, 92,

101, 102, 120, 130

Aneurism, aorta, 107 carotid, i07 of the brain, 81
Anteater, 53 Apoplexy of the brain, 118, 153 sanguinea, 117, 122 Armadillo, eye of, 53 Arsenic, 59 Arterial pulse, 23, 106
Arteriosclerosis. 39, 55, 72, 118, 129, 153, 171, 176. 212 changes in retinal vessels, 100, 150, 202 detachment, 151
neuritis, 76, Artery, central,
ciliary, 167

albuminuric, see Neuritis atrophy, see Atrophy of Optic Nerve bilateral, 80
chorioidal vessels, 100, 104, 105 degeneration of chorioid, 91, 136 differential diagnosis, 73 new formation of vessels, 80, 81, 94
unilateral, 80

Cholesterin, 130 Choriocapillaries, 113, 167. 168 degeneration of. 127, 169, 176 Chorioid, anatomy, 167 atrophic spots without visible changes in the
in the vessels, ISO, 188, 198, 200, 202, 206, 208, 210 atrophy, peri))apillary, 33, ;{9, 46, 177, 200

88
occlusion, 55, 68
82. 99,

vessels, 180 with visible changes

103,

107, 127, 146, 153, 158
cilioretinal, 23,

44

ophthalmic, 15

Astigmatism, 39, 71 Atoxyl, 59

Atrophy of

optic nerve, 51

diseases, about the optic nerve. 177 aliiuniinuria. 133, 180. 204, 212 arteriosclerosis, 54, 180 eolohoma, 33, 174, 177, 222 diabetes, 181 differences of level, 173, 181

arteriosclerosis, 52, 54 choked disk, 51, 57, 64 differential diagnosis, 52

etiology. 168

form

of,

173

glaucomatous, 52, 54, 66 gray, 52, 62, 72 interruption of conduction, 52, 62 neuritic, 52, 57, 64, 103, 190, 210 nutritional, 52, 55 occlusion of arteries, 52, 55, 68 partial, 52. 58, 68 retinitis pl(.mentosa, 52. 58, 99, 184 simple, 52, 53 [also gray] syphilis, acquired, 53 ' congenital, 76, 190, 194 total, 52 tuberculosis, 76 white, 53 Auto-intoxications, 59

fresh spots, 179 in periphery, 173 malaria, 181

oedema of

retina, 149 position. 172

prognosis, 153 region of macula, 176 ruptures. 173, 178. 200
sclerosis. 37, 46. 153, 171, 173, 181. 19S, etc. svphilis. 180. 181

tuberculosis, 179, 180 tumors, 152, 162, 173, 181
N'cssels,

25

hemorrhages, 119
proliferation of connective tissue, 182, 220 Chorioidal ring, 18

225

226
Cluiriii-rctiiiiti>,

179

Excavation, normal,

19,

56
vessels,

iilliiiininiirica, ^04<

Exudates of chorioidal
2\2
184
116

103,

130,

134,

ilisseniiiKita, 179,
sei'oiithiry, 175,

pignifiito.sa, 58, 99, l(i8, ITl,

181 ])r()lit('r:n',s, 17;}, 18J .syiM]>.itlictic. 1J7, 118
svi'liilitic,

('

Fever, 100
Eilix mas, 59 Foreign bodies, 118, 134
190, 191, 198

.'Svjiliilis

confifiiital, 175,

18(i,

Fovea, 36, 113 Foveal reflex, 3()
Fuiulus, albinotie, 35, 30
color, 31' lesions, [)lace, 10
size,

tuberculous, 179, -'U, -'Hi Ciliary vessels, 1()7 Cilio-retinal vessels, 33 Circulus arteriosus iri<lis, 108 nervi optiei, 1(>7 Cocain, 11 Coiobonia, see Chorioid Commotio retinae, 73 Connective tissue, proliferation
diorioitl, 18J, )iJO
in
tlie

11
28, 30 175, 198

normal types, 24, ])epper and salt,
snutl",

75

stij)pled, 34,
of,

38

in

the

tessellated, 25, 38

retina, lOJ, 105, 131

in tile retinal vessels, 1U3,

105

ring, IS

Glands of vitreous lamella, 127, 148, 175 Glaucoma, 14, 23, 40, 5-2, 57, 66, 120
arterial |)ulse, 107 .secondary, 101

Contraction, concentric, 51

Conns

in

atro|iliic

|>a]>illa,

51

inferior. 33, 39. 18
31. Cornea. o]>acities, 73, 170 reflexes of, 'J
3:i,

Glauconuitous atrophy, 14
excavation, 14 halo, 14
Glia, i)roliferation, 58, 103 Glioma retina% 50. 153, 164 Gunujia cerebral, 81, 83 ill chorioid, 181
retinal,

temporalis.

H

Cyanosis, 101 Cvsticercus, 81

83
a))0]ileeticus,

Depiginentation of

tlie

<'liorioi(l,

168,

175

Detaclinient of the chorioid, 181 retina. 73. lU(i. 157. KiO
alliuniinuric, 133. 1 10, 15-2 funnel-sha])eil, 153

Habitus

100

lla'moiibilia, 119 JJaiU's charts, 59, 80

gibbous, 15J, l&j tumor, 153, 163 Diabetes, 59, 73, 77, 79, 139, 134, 154 clianges in vessels in chorioi<l, 118 hemorrhages of cliorioid, 118 neuroretinitis, 135, 143 Differential diagnosis in changes of chorioid, 173 atrophies, 53 changes in retina, 113

Halo, 14, 33, 40 glaucomatous, 55, 66
senile,
10,

196
71. 101, 107,
of,

53 Hemeralopia", 174, 184
Heniiaiioi)sia, 54, 81 Hemorrhages, 119, 149

Heart disease, Hedgehog, eye

153

atrophy of optic nerve, 100
chorioid, 119 retina, 118

changes in retinal vessels, 98 conus staphyloma, 37 crescents of o))tie nerve, 33 glaucomatous, physiologic excavation, 56 medullary nerve fibers, 138
neuritis. 73 retinal hemorrhages, 118 retinal o|)acity, 119 retino-cborioidal spots, 135 retino-chorioidal vessels, 35

subdural, 83
diathesis, 119 Heiile's laver, 130 Herftell's lamp, 152, 163

Hemorrhagic

H(«uatro|)ia. 11

Horse, eve

of, 41

Hydroce'|)halus, 53, 81 Hy])eraemia of retina, 101 Hypernietro])ia, 71
retinal vessels, course of, 25, 105 Hy]>oi)hysis, 81

white spots (anatomv), 138
(etiology). 131

Diphtheria, neuritis, 73 crescents, excavations, 34 Diplopia, 76

Image, inverted, 3
upright, 8 Infectious diseases, 119 Influenza of retina, 119 Injuries, 33, 71
iirain. 81
elicn-ioid.

Eclampsia, 134

Embolism, 101

176, 183

Emphysema,

101

Endarteritis proliferans, 158 Ergotin, 99 Excavation, see Atrophy atrophic, 53 glaucomatous, 55, 66

commotio, retinal, see Commotio detachment, 151 oiitic nerve, 54, 63, 83
retina. 104, 118, 134, 151 ruj)ture of chorioid, 330 Interrujition of conductivity, 54

227
Intervasciilar spaces, 25, 28 Intoxications, 52, 59, 79
Iridocyclitis, 71
Iris, colol)onia,
Iritis, 71,

179

171

Neuritis, course of, 74 diabetica. 70, 142 diffrrcMtial diagnosis, 73 etioi(»gy. 75 in otitis, see Otitis interstitial, 70

Keratitis parenchymatosa, 170, 175

Labor, 100, 118, 212

Lamina

basalis, l(i7, 169

cribrosa, Ki, 21, (Hi elastica, l(i7, 109

supracborioidea,

IfiT,

1G9

otogenous, 72, 77, 88 otogenous, 77, 88 retrobulbar, 58, 78 sympathetic, 78, 148 sy])liililic, 75, 86 tuberculous, 70, 86, 218 Neuroneuritis, see Neuritis and Retinitis
ojjtic,

vasciilosa, 1()7, 169 vitrea, 167, 169

Nicotin, 52, 59, 81 Nystagmus, 59, 179

Lead, 59 79
Lens, opacity of, 73 Leucocytba?niia, 102, 10+, 118, 119 retinitis, 135, 150
Level,
differences, 9, 152, 173, 181
102, lOl, 105,

Ocular muscles, paresis, 15+ CEdema of retina, see Retina
O])hthalmoplegia, 54
106, 130,

Optic nerve, anatomy, 15
atro])hy.
,iei

Atrophy

Light, snbjective sensations of, 151 Lymph spaces of adventitia, 103

colobonia, 33, 178

Macula,

26, 112 changes, 176, 20-1.

hemorrhages, 83 infiammation, see Neuritis injuries, 83
interrujition, 103 tubercle, 76, 83 tunuirs, 83 Optico-ciliarv vessels. Orbit, absces's, 81 neuritis, 72, 77 tumor, 81, 100, 101

arteriosclerotic, 127, 176, 204 myo]iic, see Myopia

colobonia, 177
color, '25 coroniila, 55, 137

2.3.

57,

105

hemorrhage, 118
investigation, 7 oedema, 1+9
star, 130. 133, 138,

venous engorgement, 102

U3

traumatic i>crforation, 120 Malaria, neuritis, 73 retinal hemorrhages, 119 Mediastinal tumors, 73 MeduUatcd nerve fibers, 35, 40, 48, 102, 128 Meiosis, 54 Meningitis, 73, 76, 77, 90
serosa, 81 syphilitic, 53, 76, 190, 19+ tiiberculous, 76, 218
retinitis, 138 Metamorphn]isia, 151, 181 Methyl alcohol. 59, 78 Micro|)bthalmos, 179 Miliary tuberculosis, 125 retinal hemorrhages. 119 Ilueller's supporting fibres. 130, 169 Multiple sclerosis, 52. 54, 59, 68, 79 Mydriasis. 11. 52, 76 Myelitis (neuritis), 73

Otitis, neuritis, 72, 77, 90 dilatation of retinal vessels, 100 Otogenous neuritis, see Neuritis

Oxycephalus. 54, 72 choked disk, 81
neuritis, 72

Pachymeningitis, 82
Papilla, development of connective tissue, 83

hemorrhages, 83
hy|)era'mia, 71 indistinct, 73 large. 17, 33

normal,

16, 17,

28

small. 17

Myopia,

.35,

etc.,

44,

etc.,

105.

118,

181,

182,

206, etc.

Papillo-macularv bundles, 16, 59, 78 atrophy, 52," 59 Paralactic displacement. 9 Paralysis, 5+ Paresis of ocular muscles, 54, 59. 76 Pepper and salt fundus. 175 Perineuritis, 76 Peri]ia]iillarv atrophy of chorioid, see Chorioid Perspective dis])lacenicnt, 9
l'hoto|isias. 151

changes in macula, 176, 206 course of vessels, 25
detachment, 151

Phthisis

Pigment
Naevus of retina, 138 Nephritis, see Albuminuria

bulbi. see Uctacbinent 181 of chorioid, 23

of

chorioid,

Nerve

fibers, varicose of, 129

thickening of the lavcr
the
optic
nerve,
seg

changes, 172. etc. degeneration of retina, see Chorio-retinitis entrance of retina, 58, 64, 8S. 131. 150. 210 eiutliclium, layer of 24, 112, 167, 169
rins:.

Neuritic

atrojiby

of

Atro])hv
Neuritis. 71,
86," 100. 120 albuminurica, 75. 76. 88, 134 arteriosclerotica, 77, 88 axialis. 78. 135 bilateral, 72, 75

sjiots.

18 109

Pigmentation, sort, 172
Plethora, 100

Pneumonia,

101 neurit's. 72

PolMxtlia-Tuia. 101

81 vessels. see Central Artery fluctuations in caliber. 117 dnuinution. see Retinal Veins tortuositv. 150 pigment invasion. retinal Quinine. 153 Scarlet fever. neuritis. 82 thrombosis. 144 sei)tica. acconipan\ing stripes. pheboselerosis. see Chorioretinitis I)rolilera. 33. 99. 171. 129. retinal hemorrhages. 118. 105 sclerosis. 25 Transverse gunshot wounds. 138. 101. 53. 202 changes in chorioidal vessels. 15. 119 tumors. 55 105. 150. 26. 73. 190 phlebectasia. 103. 150 injuries. 133. 126. 35 Scotoma. obliteration. 113 Jirognosis. 104. . 51. 223 Scleral ring. 73. 57. 152 veins. U9. 146. Nerve Thrombosis of central vein 117. 208. 77. 169 Sta]ihvlonia. 99. 101. 35 veriini. 99. 148 neuritis. 214 of brain. 53 Purpura.j:i. 234. see Atrophy Technique. 210. 104 embolism. 134 definition of. see Ciunima neuritis. 75. 121 Sinus cavcrnoMis. 129. 76. 175. 73. 86 . 102. 72. prognosis. IW 222 Sclerosis of retinal vessels. 57. 138. 153 vessels. otitis. see Atroj)hy changes. 130 Synco|ie. 77. 119 diffuse opacities. 24. 104. 46.S)ihcnoidal sinus. 129. lU'Uritis. 102. alb'uminnrica. 34. 11. 133. . 153 Tortuosity of vessels. 19. 138 fibrinous exudates. 119 retinitis. 75. 11 atrophy. 59. 76 changes in retinal choked disk. 117. 125. 149. 35. 72. 125. 81 of optic nerve. jjosition of. 76 Retinitis. 117. 214. 208 Stijipled fundus. 105 Retinitis. lieniorrliages. 174. 146. 76. 103 lym]>h sjiaces. 117 Tiilicrcle of ehorioid. 128 posticum. see Migrating Pigment prognosis. 57. 1 Ki Sepsis. Snuff fundus. 3 Temporal detachment. 20. 99 atrophy. 122. 10 Uetina. 117. 122 99. 130. 153 delacliment. 75. 57. 130. 54. 135. 122. 78 aneurism. 133. 55. 114. 25. 115. 102. 138 intiltration with white hlood corjniscles. 99 Syphilis. see Detachment differential diagnosis. 99. see Multiple Sclerosis Sclerotic vascular ]ilexus. 73 Ptosis. 101 fatty degeneration. etc. 135. 38. 23. see Glaucoma increase. 105 Uefraction. chorioidal .1 Porcupine. 86. 64. 156 127. 59 Raliltit. 102. 198 8fi. 100. 51 Pupilla. 55. 131. 186. 77. 130. 144. 58 Rhinoceros. ana?mica. 181. 153 reflexes. 130. 106. 99 reflexes. 86 retinal hemorrhages. 150. 113. 144 Tabes. 10 innniil)ilily. spots. 190. diffusa. 169. IKi. 72 (S'(7iirf(«n's sheath. 26. 103. l)laek. see Chorioretinitis. 206 ruptures. 68. 53. 98 color. 150. 103. neuritis. 129. accompanying. 10«. 71 differential diagnosis. 100. 129. 173. 144 102 contraction. 179. 156 Retraction crescent. 103. 212 dilatation. 104. see Atrophy of Optic 78. 181. 134. 28 Strabismus. 135. 122. 150. 190. 79 Spots. 53 I'rejiMiiiH'y. 153 Pseudo-neuritis. 174. 100. eye of. HeHex light streak. 153. 37. 18 \'essels. 104 lime deposits. 15 Sclerotico-chorioideal canal. 44 Svmpathetic inflammation.Stri])es. prognosis. 59. 103 Keflex of retinal vessels. 102 Supertracti(ui crescent. 102. 7S. 154 156 proliferans. 132 syphilitica. 79. 115. 99. 152. 54. 202 thrombosis. 152 gunuiia. anatomy. 73. 119 Sdelis' lamj). 101 thrombosis. 190-202 detachment. 178. 135 circinata. 81. 101 congenital. thrombosis of. 59. 212 I'rogiiosi. 103 new formations. 179 97. 174 white. 125 hemorrhages. 101. 135. 181 Scurvy. 114 diabetica. 102 jihvsiological differences. 119 white spots. 136. 22. 208 pulsation.s ill changes of retina ami ehorioid. eye of. Synchysis scintillans. 153 glaucoma. 16 Scleractasia. 72 oedema. 90 Small))<)x. 82. central. 76. dilation. 118. 182 Trunk. B4. 92. see Retinal Vessels multiple. 26. 149. determination of. 99. 149 Icncirniica. 122. 153. 119 Secondary glaucoma. 19. 135. 180. 57. 36 Rctriibnibar neuritis. 150 jjiguuiitosa.

luO. 54 loss of sectors. 73 prognosis. 23. Typhoid. transverse gunshot. brain. 105 retina. 153 neuritis. 23. 26 Weiss' reflex ring. 119 133 purple. retinitis. 54 field. 1»3 Zinn's sclerotic vascular plexus. ~-2 Venous Visual pulse. 151 intraocular. 44. hemorrhage into. thrombosis. see ophthalmica. 173. 181 detachment. 119 Wounds. 106 concentric. hemorrhages of retina. 100 Uraemia. 134 Varicose thickening l-'9 of the laver of nerve Weiss-Otto shadow ring. 34 Vitreous. 15 Thrombosis . Vena centralis. see Brain chorioid. 154 recurrent. 15. 68. 15:?. 168 fibers. 119 Ulcus ventriculi. 118 opacities. 52. retinal hemorrhages.229 Tumor. 36 Werlhoff's disease.

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