THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES ^OTT^ ATLAS AND EPITOME OPHTHALMOSCOPY Ophthalmoscopic Diagnosis BY PROF. DR. O. HAAB of Zurich SECOND AMERICAN EDITION FROM THE FIFTH REVISED AND ENLARGED GERMAN EDITION EDITED BY G. E. DE SCHWEINITZ, A.M., M.D. Professor of Ophthalmology in the University of Pennsylvania and Ophthalmic Surgeon to the University Hospital ; Consulting Ophthalmic Surgeon to the Philadelphia Polyclinic ; Ophthalmic Surgeon to the Phila- delphia General Hospital ; Ophthalmologist to the Ortho- pedic Hospital and Infirmary for Nervous Diseases With t52 Colored Liihographic Iltusirations PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 19 10 Set up, Electrotyped, Printed, and Copyrighted May, 1901. Reprinted September, 1904, March, 1905, and March, 1906. Revised, Reprinted, and Recopyrighted March, 1909 Copyright, 1909, by W. B. SAUNDERS COMPANY Raprinted March, 1910 PRINTED IN ANfcRICA PRESS OF SAUNDERS COMPANY PHILADELPHIA vouP EDITOR'S PREFACE TO SECOND EDITION The continued favor which has been accorded to Pro- fessor Haab's Ophthalmoscopy and Ophthalmic Diagnosis has made necessary a new edition, in which the subject- matter has been brought up to date and a few new chromo-lithographs have been added, several from Pro- fessor Haab^s collection and one from the collection of the editor. It can scarcely be doubted that this book will prove in the future, as it has in the past, of the greatest use to those w'ho desire to study and teach Ophthalmology. EDITOR'S PREFACE TO FIRST EDITION The great value of Professor Haab's Atlas of Ophthal- moscopy and Ophthalmoscopic Diagnosis has been fully established, and entirely justifies an English translation of his latest edition. Not only is the student made ac- quainted with carefully prepared ophthalmoscopic draw- ings, done into well-executed lithographs, of the most important fundus-changes, but in many instances plates of the microscopic lesions are added. The whole fur- nishes a manual of the greatest possible service, not only to the beginner in ophthalmic work, but to one who has already far advanced and desires to compare the observa- 3 4 PREFACE tions of his own service with those of the rich clinic from which Professor Haab has gathered his phites. A few figures have been added by the editor — namely, those showing Angioid Streaks in the Retina, and the Ophthalmoscopic Appearances seen in Arteriosclerosis. As in the Atlas of External Diseases of the Eye, produced under the same editorship, occasional comments are placed in brackets. It is sincerely trusted that this book will prove of great use to those wdio desire to study and teach Ophthalmology. PREFACE TO FIFTH EDITION Although this atlas was already very much greater than the first edition, it was nevertheless possible, thanks to the kindness of the publisher, to enlarge the present fifth edition by the addition of two illustrations of birth injuries of the eye. An illustration of pigmentary de- generation of the retina which was not quite satisfactory was replaced by a better one. In addition, several of the earlier illustrations were retouched and corrected in various ways. Some corrections and additions have also been made in the text, and it is hoped that this edition, like its predecessors, may meet with the approval of the profession. O. Haab. PREFACE TO THE SECOND EDITION. The kind reception accorded to this volume in various countries induced me to make a number of additions and corrections before the book went through the second edition. Besides adding to the text, I enriched the illustrated portion of the work by a number of anatomic figures to illustrate the differences between normal and pathologic appearances of the eye-ground. They are intended to explain the things seen under the micro- scope and their topographic relations, thus enriching the student's pathologic knowledge and enabling him to in- terpret more accurately the clinical pictures presented by the various diseases. A few of the original ophthalmoscopic pictures have been replaced by better ones, and two have been added that are entirely new (retinitis circinata and true staphy- loma in myopia). For the preparation of the anatomic figures I am indebted to the skill of our academic artist, Mr. L. Schroter. Although the pupillometer (Fig. 80, a) does not, strictly speaking, belong to the subject of ophthalmoscopy, I have, nevertheless, yielding to a long-cherished desire, incorporated it in this book — which is, above all, in- tended for practical, every-day use — believing that many 5 6 PREFACE TO THE SECOND EDITION. practitioners who feel the necessity of determining the size of the pupil more accurately than is possible by mere inspection will find it a welcome addition to their clinical armamentarium. Finally, I wish to express my grateful recognition of the great care and effort bestowed on the preparation of this Atlas by the publisher. O. HAAB. CONTENTS. PAGE Introduction 13 Description of the Ophthalmoscope 18 Examination in the Erect Image 23 Measurement of the Myopic Eye 26 Measurement of the Hypermetropic Eye 29 Measurement of Astigmatism 34 Size of the Ophthalmoscopic Field of Vision 38 Examination by the Indirect Method 40 Size of the Visual Field 42 Enlargement of the Image in the Direct and in the Indi- rect Methods 43 Measurement of Refraction by the Indirect Method ... 45 Determination of Irregularities in the Surface of the Eye- ground 45 Examination by Transmitted Light 47 Shadow-test, or Skiascopy 53 Choice of an Ophthalmoscope 58 Method of Conducting an Ophthalmoscopic Examination 67 Normal Eye-Ground 74 Pulsation Phenomena 82 INDEX 89 7 ILLUSTRATIONS FIG. 1. 2, a, b. 3. 4. 5, a, b. 6. 7. 8, a. 8, b. 9, a. 9, h. 10, a. 10, b. 11. 12, a, b. 13, 0, b. 13, A. 14, a-c. 15, a. 15, b. 16. 17. 18. 19, a, b. 20, a, b. .21, a. 21, b. 22. 28, a, b. 24, a. Normal Eye-ground. Section of a Normal Papilla. Section of the Retina, Choroid, and Contiguous Sclera in a Normal Eye. Normal Eye-ground (Blonde). Normal Eye-ground (Dark). Medullated Nerve-fibers in the Retina. Congenital Circumscribed Defect of the Choroid. Congenital Circumscribed Defect of the Choroid and Mal- formation of the Optic Nerve. Congenital Defect of the Pigment-epithelium of the Retina. Congenital Circumscribed Defect of the Retinal Pigment and the Choroid. Congenital Circumscribed Defect of the Choroid. Congenital Circumscribed Defect of the Choroid. Congenital Absence of Pigment. Congenital Dislocation of the Lens. Inflammation of the Optic Nerve. Inflammation of the Optic Nerve in Brain-tumor. Optic Neuritis (Choked Disc) and Macular Changes in Brain- tumor. Horizontal Section of a Normal Macula Lutea. Section through the Papilla in Neuritis. Section through the Papilla in Neuritis and Papillitis. Inflammation of the Optic Nerve and Retina in Syphilis. Intense Inflammation of the Optic Nerve. Inflammation and Congestion of the Optic Nerve in Orbital Tumor. Atrophy of the Optic Nerve. Gray Atrophy of the Optic Nerve. Section through Entrance of the Optic Nerve in Partial Atrophy. Section through the Disk in Total Atrophy of the Optic Nerve. Atrophy of the Optic Nerve from Glaucoma. Glaucomatous Excavation of the Optic Nerve. Section through the Region of the Angle of the Antei-ior Chamber. 10 ILLUSTRATIONS. Section through Same Kegion, showing Obliteration of Angle. Section through the Head of the Optic Nerve in Glaucoma. Retina and Optic Nerve in Albuminuria. Section through the Retina in Retinitis Albuminurica. Varicose Nerve-fibers. Retina in Retinitis Albuminurica. Albuminuric Changes in Retina ai>d Optic Nerve. Albuminuric Disease of the Eye-ground. Albuminuric Retinitis of Both Eyes. Eye-ground in Diabetes. Eye-ground in Pernicious Anemia. Obstruction of the Central Artery. Thrombosis of the Superior Temporal Vein. Thrombosis of the Central Vein of the Retina. Obstruction of the Superior Temporal Artery of the Retina. Recurring Hemorrhages in the Retina and Vitreous. Syphilitic Disease of the Retinal Arteries. Syphilitic Neuroretinitis and Disease of the Retinal Arteries. Angioid Streaks in the Retina. Changes in the Eye-ground in Arteriosclerosis. Pigmentary Degeneration of the Retina. Eye-ground in Hereditary Syphilis. Eye-ground in Congenital Syphilis. Secondary Pigmentation of the Retina in Disseminated Choroiditis. Disease of the Macula Lutea due to Myopia. Secondary Pigmentation of the Retina. Sagittal Section of an Eye with a Total or Funnel-shaped Retinal Detachment. d. Pigmentary Degeneration of the Retina. Disease of the Macula Lutea due to Old Age. Disease of the Macula Lutea (Traumatic). Perforation of the Macula Lutea after Contusion of Eyeball. Macula Lutea and Surroundings in Disease from Orbital Tumor. Retina in Thrombosis of the Vena Centralis RetinoB. Opacity of the Retina. Disease of the Macula Lutea due to Foreign Body. Disease of the Macula Lutea due to Pressure and Contusion. Injury of the Retina by an Iron Splinter. Air-bubble in Vitreous. Old Injury of the Retina by an Iron Splinter. FIG. 24, h. 24, <^, d. 25, a. b. 26, a. 26, f>, c. 27. 28, a. 28, h. 29, o, b. 30, a. b. 31. 32. 33, a. 33. b 34. 35. 36. 37. 37, a. >37, b. 38, 39 40. 41, 42 43. 44, 45 46, a. 46, b. 46, c, d. 47. 48. 49. 50, a. 50, b. c. 51, 52, 63. 54. 55. 56. 57. ILLUSTRATIONS. 11 FIG. 58, a. Point of Impact of a Foreign Body on tlie Eye-ground. 58, 6. Ketinal Bands due to Traumatism. 58, I, a. Changes in Eye-ground Resulting from Severe Forceps Delivery. 58. I, h. Atrophy of the Optic Nerve and Retinal Vessels ; Macular Disease ; Strand of Connective Tissue in Vitreous. 59. Retinal Detachment in the Temporal Portion of the Eye- ground. 60. Retinal Bands and Detachment after a Punctured Wound. 61. Retinal Detachment at the Inner Upper and Lower Portions. 62. Retinal Detachment with Laceration. 63. Hemorrhagic Retinitis of Pregnancy. 64. Retinitis Circinata. 65. Eye-ground in Leukemia. 66. Glioma of the Retina. 67. a. Retina in Pernicious Anemia. 67, 6. Small Inflammatory Focus in Disseminated Choroiditis. 68, 69. Disseminated Choroiditis. 70. Infiltrations of the Choroid in Disseminated Choroiditis. 71. Disseminated Choroiditis in the Early Stage. 72. a. Hyaline Bodies (Drusen) in the Vitreous Layer of the Choroid. 72, 6. Senile Pigmentation of the Retina. 73, a. Recent Disseminated Inflammation of the Choroid, Over- lying Retina, and Optic Nerve. 73, 6. Disseminated Choroiditis. 74. Chronic Disseminated Choroiditis and Secondary Pigmenta- tion of the Retina. Miliary Tubercles in the Choroid. Chronic Tuberculosis of the Choroid. Sarcoma of the Choroid. Recent Disseminated Choroiditis. Changes in the Choroid due to Contusions ; Lacerations. Sclerosis of the Choroidal Vessels ; Disseminated Choroiditis and Secondary Pigmentation of the Retina. Hyaline Bodies (Drusen) of the Vitreous Layer. Miliary Tubercle of the Choroid. Large Tubercular Growth in the Choroid. Choroidal Sarcoma. Atrophy of Choroid in Myopia. True Staphyloma. Posterior Venae Vorticosae. Pupillometer. OPHTHALMOSCOPY INTRODUCTION. Examination of the eye-ground by means of the ophthalmoscope is of the highest importance for the recognition not only of many affections of the eye itself, but also of a great number of diseases chiefly affecting organs outside of the eye, as the brain, the kidneys, or the circulatory system, and endangering life either by disturbing the general nutrition or by setting up a general infection. The wide lymph-spaces of the eye and the rich network of vessels in the retina offer a favorable soil for the development of many pathogenic germs and toxic substances present in the body. This is especially noteworthy in syphilis, both in the hereditary and in the acquired variety, although the effects of tubercular and rheumatic infection of the organism also not infre- quently manifest themselves in the eye. For these reasons ophthalmoscopic examination of the eye-ground is one of the most important methods of medical examination. Unfortunately, it is also one of the most difficult. This is partly because the familiar- ity with the technic of the ophthalmoscope necessary for obtaining a clear image of the eye-ground requires a certain amount of training and practice, and partly because the correct interpretation of the ophthalmoscopic injage is often a very difficult matter. An astonishing variety of pictures may be seen in the interior of the eye. The image of the eye-ground varies greatly even in con- ditions of health, and it is anything but easy for the beginner in the art of ophthalmoscopy to determine, 13 14 OPHTHALMOSCOPY. in many instances, whether the conditions present are normal or pathologic. If, for instance, he should de- scribe the fundus of the eye as " abnormally reddened, '^ an expert would know that he has to deal with a beginner. Still more difficult is the interpretation of the numer- ous deviations from the normal which may be seen in the eye-ground. It is comparatively easy for one who sees only the coarser variations, because he fails to utilize the instrument to its fullest extent, or because the in- strument itself is imperfect, or, possibly, because his eye is not sufficiently well-trained or is defective, or his ex- amination is too hasty. Even the expert often finds the greatest difficulty in seeing and correctly interpreting the more minute pathologic alterations in the eye-ground. Practice and experience, both the examiner's own and that of other observers, in this, as in many other cases, will prove to be the best guides. The latter may be either described in words or illustrated by pictures which more or less faithfully reproduce pathologic alterations. Mere verbal descriptions are even more unsatisfactory than they are in other similarly complicated domains of medicine, especially if the student is imperfectly acquainted with the subject. Even topographical draw- ings of pathologic alterations in the eye are extremely complicated, and a correct description of the coloring is often extremely difficult or even impossible. Thus, a little more white, or a little more red or gray, may make an important difference in the appearance of the optic nerve, and may be enough to show the expert that he has to deal with a serious condition, though to the inexperienced eye the appearance may be normal. It is for this reason that the examination of the eye-ground by means of the ophthalmoscope offers an excellent means of training the eye for the perception of the finest shades of color — a most useful faculty for enabling one to recognize many other morbid alterations in the body. Black and white pictures of the eye-ground have, therefore, very little A INTRODUCTION. 15 value. They may reproduce the drawing and topog- raphy, but as they fail to give the important element of color, they can be understood and utilized only by one who already possesses a fair knowledge of the conditions portrayed.^ To supplement one's own observations and profit by those of others, one must use carefully colored illustrations. Although we already possess a great number of illus- trations of the eye-ground, both in the usual atlases and in other works, I am none the less determined to publish this epitome and atlas of ophthalmoscopy. In the first place, the pictures that exist, especially those that are scattered through the literature, are not accessible to everyone, and I find that many a picture which would be useful to the student, to the practising physician, or to the clinical teacher for the purpose of study and demon- stration, is not found in these works. Too many of the pictures reproduce rare conditions which even a man of large practice might not see more than once or twice in his experience. Again, many pictures of immense practical importance, especially such as illustrate sub- varieties and different stages of the same morbid process, are often left out. Thus, for instance, it is impossible to explain to the beginner the variations of the retina and optic nerve in albuminuria by means of one or two pictures, or the manifold forms of chronic choroiditis with three or four illustrations. Accordingly, I have tried to avoid showing very rare conditions, and have instead collected as many pictures of practical importance as possible. All the ophthalmoscopic images contained in this volume were drawn from life by myself in the course of my practice, and the original ophthalmoscopic pictures are also of my own preparation. In doing this work the sketch-book^ was found extremely useful, ^ It is very mucli to be regretted that the illustrations in the excellent work by Gowers, Medical Ophihahnoscopy, are not all colored. 2 Sketch-book for Ophthnlmoscopic Observations of the Ei/e-ground, second edition, unbound. Published by J. F. Lehman, in Munich, 1898. 16 OPHTHALMOSCOPY. because it combines rapid execution with the greatest possible degree of accuracy in reproducing the various shades of color. With the exception of three (Figs. 10, b, 39, and 45, a), all the original pictures in this book have been prepared according to my own method, and I am convinced that it is the easiest, and what is more impor- tant in drawing from life, the quickest method of obtain- ing a picture of all the alterations seen in the eye-ground. To become an expert in the beautiful art of ophthal- moscopy it is necessary to do a great deal of drawing from life. I have become more and more convinced of this during the preparation of the pictures in the present volume. The eye-ground would be studied with much more care if the student were to draw ^ what he sees, and especially if he were also to reproduce the colors. The benefit derived from a course in ophthalmoscopy will be very much greater if the student draws what he sees. I constantly regret that our medical students are, as a rule, so badly instructed in the art of drawing, and that so few of them can be expected to produce a fairly decent pict- ure ; but even an imperfect picture is better than none at all for beginners. It is particularly desirable for the student and prac- tising physician to have his ophthalmoscopic pictures in a more convenient form than the usual atlases, and the idea of presenting them in book form seems to me an excellent one. The pictures in this volume are represented as they appear in the inverted image ; that is to say, with mod- erate magnification, although I, of course, also used the more highly magnified image obtained by the direct method in preparing the sketches which are taken from life. The figures, therefore, present a moderately en- larged image of the eye-ground, leaving out many con- 1 Slcetch-booTc, p. 4 : " The ophthalmoscopist who possesses any proficiency in the art of drawing will notice, incidentally, that the drawing of these sketches sharpens his powers of observation and impresses the picture more firmly on his memory. If we intend to draw a thing, we are forced to observe it much more accurately." INTRODUCTION. 17 ditions which naturally confuse the beginner and are unnecessary for the expert, such, for instance, as the reflexes of the retina and vessels, and the delicate, irreg- ular mosaic arrangement of the pigmentation of the fundus, etc. These details, which are seen chiefly in the upright image, are very troublesome to reproduce in lithographic plates, especially when one considers that the lithographic reproduction of even a small image of the eye-ground presents great difficulties. I therefore directed all my efforts to obtaining in every instance an absolutely faithful reproduction of whatever is typical or pathologic. The pictures have been so colored that when seen in daylight they produ(5e the impression re- ceived in looking at the eye-ground with artificial light ; in other words, the whitish parts (optic nerve, etc.) when seen by daylight are not as yellow as they are in the original sketches, which were made by artificial light. In an artificial or yellow light a moderately deep yellow color appears white, hence pictures prepared by artificial light are too yellow and must be made more white if they are to produce the same impression by daylight. The pictures in Jager's large atlas are colored in such a way that they appear correct by artificial light; but if they are examined by daylight the unnaturally yellow color of the lighter portions becomes a disturbing factor. My pictures, on the contrary, are a little too white by artificial light, but to judge from all the pictures in ordinary use this is neither a serious nor a disturbing defect. In his smaller atlas Jager, in accordance with the custom which arose later, also made his pictures more white ; but, it is to be remembered that Jilger's pictures were prepared with Helmholtz's ophthalmoscope, so that in many of them the gray, and particularly the green, shades in the optic disk are unusually prominent (for instance, in the picture of glaucoma). In my pictures the coloring is such as it appears with the stronger ophthalmoscope, which, for reasons to be given later, I use exclusively in the examination of the eye-ground. 2 1 8 OPHTHALMOSCOPY. DESCRIPTION OF THE OPHTHALMOSCOPE. Before the jjM'ention of the ophthalmoscope by H. v. Hehiiholtz, in 1851, our knowledge of the interior of the eye in the living subject was as dark as the pupil itself. Until the invention uf our beautiful instrument the world had no conception of the interior of the eyeball as we now see it with the ophthalmoscope in all its lucidity and wealth of coloring. Most of the pathologic alterations visible by means of the ophthalmoscope were not even properly known at that time. Why is it that w^e cannot without the aid of an appro- priate instrument penetrate into the depths of the eye? Why is it that the interior of the eye and the pupil appear black except in a man or animal devoid of pig- ment (albino)? The conditions are exactly the same as when we look into a camera obscura — as, for instance, a photographic apparatus open and ready for the reception of an image — although we know that on the sensitive white plate at the back of the instrument there is an accurate colored image of the objects in front of it, w^e cannot see a trace either of the white plate or of the picture. To us the interior of the camera and the opening through which the rays of light enter appear black, and all that we see in the lens occupying this opening is a minute image of ourselves, such as may be seen in the cornea of the eye. No one acquainted with the most elementary laws of optics will have any difficulty in understanding why the pupil appears black, and why, without special instru- ments, we are unable to look into the interior of an eye. As in the camera obscura, the refracting system of the eye, which is a double lens consisting of the cornea and aqueous humor, throws a reduced inverted image on the retina. This image appears sharply outlined if the eye is properly focussed for the object, and blurred — that is to say, in diffusion circles — when the eye is not prop- erly focussed, just as in the photographic camera. DESCRIPTION OF THE OPHTHALMOSCOPE. 19 Now we learn from one of the laws of the refraction of lenses that object and image bear a definite relation to each other — they are said to be reciprocal or conjugate — so that they may be interchanged without necessitating any alteration in the dioptric system or in the distances from the lens to the object and to the image. If in a dark room we obtain on the disk of ground glass a clear image of a candle held at a distance of one meter in front of the object-lens, and then put the light in the place of the ground glass, we will get a clear image of the flame by holding the ground glass where the light originally was, that is to say, one meter in front of the lens. In other words, we may reverse the positions of the candle and of the ground glass, and in each case obtain a sharp image of the candle, providing we retain the original dis- tances — in the former case behind, and in the latter in front of the lens. The rays of light emitted by the image on the ground glass, after leaving the apparatus, all return to the flame of the candle. But as our eyes do not send out any rays of light when we look into a dark chamber, they cannot receive any rays in return ; hence the open- ing of the camera and the object-lens appear dark, and in the same way the opening of the eye into which we are looking ; in other words, the pupil also appears dark. If, however, rays of light are sent out from the ob- server's eye, the rays which enter the observed eye return to the eye of the observer, and the pupil of the observed eye appears red like that of an albino. Before the inven- tion of the ophthalmoscope an erroneous theory was cur- rent that the pigment of the fundus absorbed all the light that enters the eye, and the {)upil of a pigmented eye there- fore appeared black. If the eye-ground of a normal eye is illuminated by rays emerging from the observer's eye, 'enough rays will be reflected by the eye-ground, which even in a pigmented eye is not entirely black, to enable the observer to get a clear image of the other eye. On the other hand, the pupil of an albino is red, not because of any want of pigment in the fundus, but because of the 20 OPHTHALMOSCOPY. absence of pigment in front, so that the rays of light pass through the iris, sclera, and choroid, and illuminate the eye at every point instead of only at the focus of the re- flecting media. In such eyes there is no reciprocal rela- tion between the object and the image ; the rays emerge from the pupil in all directions, and the latter appears in a red light because the eye-ground of the albino (in man, in the white rabbit, etc.) is colored red by the numerous blood-vessels of the choroid. If in the albino the light is prevented from entering the eye in this abnormal way through the unpigmented tissues outside the pupil, and the pupil is then examined, it will appear as dark as in the ordinary individual. This can be done by holding immediately in front of the albino's eye an opaque cup with an opening corresponding in size to the pupil. If the light is allowed to enter only through this opening and through the pupil, the latter will appear as black as that of a pigmented eye. Now we can by means of any simple device, and best by means of the ophthalmoscope, send out light from our own eye. Even an ordinary glass disk held in front of the eye, by virtue of its reflecting qualities, w^ill direct into the eye the rays emanating from a light standing to one side. If the light is placed to the left of the person examined, and the glass disk is turned slightly toward the lamp, so that the reflection of the light falls on the observed eye, the pupil wall immediately a])pear red when seen through the piece of glass (cf. Fig. A). As the rays coming from the lamp {L) are in part reflected into the observed eye by the glass disk, they enter it in such a way that they appear to come from a point behind the observer's eye, that is, from the point X2, which would correspond to the reflected image of the lamp. Since they enter the observed eye they illuminate the eye- ground. If the eve is focussed for the distance of the reflected image of the lamp, a clear image of the lamp will be produced on the fundus ; but if the eye is not focussed for this distance, the image will be blurred. In DESCRIPTION OF THE OPHTHALMOSCOPE. 21 any case a certain portion of the eve-ground of the ob- served eye is illuminated and thereby enabled to send back rays of light. These rays return to the object — in this case the flame of the lamp. As the disk of glass not only reflects but also transmits light, a portion of the rays returning from the observed eye pass through the glass and enter the observer's eye, while the remainder are reflected toAvard the lamp and lost to the observer. But the amount of light entering the observer's eye in this way is very slight and the illumination of the pupil Fig. a. — Illumination of the eye luuler examination iVn.) by means of the glass disk, GL; two of tlie rays coming from a point in the light (L) are shown ; one of these rays, after being reflected by the glass plate, misses the eye; part of the other ray passes through the glass {Gl.) and is lost to the observer (5^.), while the remainder is reflected into the eye of the person examined {Un.), returns by the same path, and enters the eye of the observer in the direction of L-i, the reflected image of the eye ; S, S, perpendiculars to Gl. of the observed eye correspondingly weak. The light may be increased by adopting Helmholtz's plan of laying several glass disks one upon the other, but even with such an arrangement the amount of light entering the observer's 'eye is comparatively small. A much better result is ob- tained by throwing more light into the observed eye, so that the eye-ground is more powerfully illuminated and accordingly sends back more light, and, secondly, by allowing the returning rays to enter the observer's eye 22 OPHTHALMOSCOPY. without being weakened ; that is to say, tlirough a hole in the mirror. Accordingly, Helmholtz's disks were soon replaced by a true mirror which throws much more light into the eye. By scraping away the coating from a small spot in the center an opening was obtained for the returning rays to enter the observer's eye. The amount of liglit entering the eyes, both of the observed and of the observer, may be still further increased by using a concave mirror which concentrates the light before throwing it into the observed eye, and by making an actual opening at the center of the mirror, so that the returning rays meet with even less resistance in their passage through the mirror. By thus illuminating the eye with the rather weak Helmholtz ophthalmoscope, or better, with the somewhat stronger but still comparatively weak plane mirror, or, best of all, with a powerful concave mirror, we can obtain a distinct view of the otherwise invisible eye- ground. As the illuminated fundus sends out rays of light which enter the observer's eye in the manner ex- plained, it is evident that the observer obtains in his own eye a clear image of the eye-ground observed. The fun- dus of the observed eye is converted into a luminous object which we can see like any other object in the out- side world. Strictly speaking, however, we see the eye- ground as we see an object through a magnifying glass, the reflecting media of the observed eye forming a lens through which we see the individual portions of the eye- ground under a high magnification. Some persons require additional aids to obtain a clear view of the eye-ground by the method just described. This method of examination is known as the direct method or the method loith the erect image. It is called the direct method because it enables a normal eye to examine another normal or hypermetropic eye without any additional aids. It is called the examination with the erect image because we see the eye-ground right side up like any other object in the outer world. EXAMINATION IN THE ERECT IMAGE. 23 I. EXAMINATION IN THE ERECT IMAGE. Without certain devices to alter the direction of the rays of light emerging from the patient's eye, this method of examination is often impossible, and this brings us to a further and very important feature of ophthalmoscopic examination. It appears that the ophthalmoscope not only enables us to see the things ^vhich are to be seen in the eye- ground, but also furnishes us with the means of accurately measuring the refracting power and the structure of the observed eye ; and these data are most valuable, since they are entirely objective and render us independent of the patient's statements. To do this we use our own eye, the refractive system of the eye examined, and possibly certain convex or concave lenses, and thus calculate in the simplest possible manner the optical power of the observed eye. To understand this it is necessary first to consider the manner in which the entering rays leave the eye in the case of a normal, a myopic, and an hypermetro])ic organ. As has been explained above, the rays of light always return to the point from which they have come and on which the eye is therefore focussed — in the above exam- ple the flame of a candle fixed at a distance of one meter in front of the eye. In this case the eye is accommodated for the distance of one meter. An emmetropic eye Avith- jout accommodation is, of course, focussed for infinity ; Ithat is to say, for parallel rays. The fundus of such an eye, therefore, reproduces a clear image of all objects 'sending out parallel rays of light ; in other words, of all distant objects. As the diameter of the pupil is very small, an object may be considered distant if it is 3 to 5 meters away from the eye; that is to say, the error of considering rays coming from such a point as parallel rays is infinitesimally small. When, therefore, an em- metropic eye looks into infinity or looks at an object 3 to 5 meters away, the rays of light leaving the 24 OPHTHALMOSCOPY. illuminated eye-ground also return to infinity and are therefore parallel (cf. Fig. C). It follows that if we examine an emmetropic eye by the above-described direct method, the rays of light emerging from the eye imme- diately form a clear image of the fundus on the observer's eye, providing the observer also looks into infinity ; in other w^ords, adjusts his eye to parallel rays. If the observer accommodates instead of looking into infinity, he will obtain a blurred image of the observed eye- ground; but as in order to look into an eye one has to get as near to it as possible, just as when looking into a room through a key-hole, it is somewhat difficult to relax the accommodation. This is one of the greatest difficulties encountered by the beginner in attempting to examine by the direct method. It is, however, absolutely indispensable if he wishes to obtain a correct measurement of the refraction of the observed eye ; in other words, the observer's eye, in order to measure the refraction of another eye, must ! relax its accommodation completely, because it is impos- sible to calculate the increase in the refractive power of ! the observer's eye due to the accommodation. We can measure our own accommodation only when we know for what distance, that is to say, for what degree of diver- gence of the rays entering our own eye, it is focussed ; but the very object of an examination by the direct method is to determine the divergence of the rays of light which leave our own eye. It follows from what has been said that the observer must know the exact refractive power of his own eye in order to be able to measure that of the patient's eye. If the observer is emmetropic, he gets a clear image of the eye-ground of the patient's eye without any further ap- pliances. If he is myopic, he will obtain a blurred image, as everything that sends out parallel rays, or in other words, is at an infinite distance from his eye, appears blurred. To see distant objects the myope needs spectacles with concave lenses ; hence to examine EXAMINATION IN THE ERECT IMAGE. 25 by the direct method the myope must also use a correct- ing glass, which he places behind the opening in the oph- thalmoscope, if he wishes to obtain a clear image of the eye-ground of the emmetropic eye. If the observer is hypermetropic, he is in the same position when he attempts to examine by the direct method as when he looks into infinity; he must, since his eye is not focussed for parallel rays, either wear a correcting glass with convex lenses or accommodate. But as he is not allowed to resort to the latter expe- dient, he must, during the examination, use a glass which completely corrects his hypermetropia. His hy- permotropia must be completely corrected, so that he may not be forced to compensate for some unknown degree of hypermetropia by using his accommodation. This is particularly difficult for the hypermetrope, be- cause he has become so accustomed to correct his optical error by accommodating that he finds it very difficult to substitute a correcting lens for his power of accommoda- tion. He continues to accommodate even when looking through the correcting lens — at least to some extent — and is accordingly over-corrected. This is particularly the case in high grades of hypermetropia when the individual is young and the power of accommodation is well pre- served. Surgeons with moderate hypermetropia are, therefore, often compelled to resort to some other means of meas- uring the refraction if they do not wish to depend on the patient's statement — either to Schmidt-Rimpler's method by means of the inverted image, or to the shadow-test. These two methods will be discussed later. We have assumed up to this point that the person examined is emmetropic and that the observer is emme- tropic, myopic, or hypermetropic. What is the condition of affairs when it is desired to examine an eye with ab- normal refraction? We must first determine in what way the rays emitted by an illuminated eye-ground leave the eye in the case of myopia or hypermetropia. Again, 2S OPHTHALMOSCOPY. we assume that the ametropic eye under examination looks into infinity, so that the accommodation, which we cannot compute, may be disregarded in the calculation. The patient, whether he be emmetropic or ametropic, must always relax his acconamodation while his refraction is being taken. Measurement of the Myopic Eye. A myopic eye, when it is not accommodating, is focussed for a point at a finite distance, depending on the degree of myopia. This point is known as the /ar point (punctum remotum). It is the farthest point at which an eye of this kind sees distinctly. Only those rays which come from this point are collected on the retina and form there a distinct image, when the eye is looking into infinity without accommodating. Rays com- ing from a more remote point are focussed in front of the retina, and the image formed on the retina is blurred. The reason that the image is formed in front of, instead of on the retina, as in the normal eye, is usually that the myopic eye is too long (cf. Fig. D) or that the refracting power of the lens is too great. Excessive length of the eyeball is the chief cause of myopia. In order to see distant objects distinctly, the myopic eye must be corrected by means of a concave lens which weakens the refraction, so that the entering rays are focussed on the retina, behind the focus of the lens. Let us now consider how the rays emanating from an illuminated portion of the eye-ground in a myopic eye leave the eye after traversing the refractive media in the contrary direction. If the eye docs not accommodate, they will tend to converge at the far point (cf. Fig. D), since the far point is at a finite distance from the eye («', 6', plane of the far point). If the far point is situ- ated at a distance of one meter from the eye, the degree of myopia is equivalent to a lens of one-meter focus (diopter), and the error in such a case is corrected by means of a lens having a focal distance of one meter. If the far point is situated at 0.5 meter from the eye, the EXAMINATION IN THE ERECT IMAGE. 27 error is twice as great and the correcting glass must be twice as strong ; that is, a glass equivalent to two meter- lenses or diopters ; or, in other words, a lens having a Fig. B Fig. C. Figs. B, C, D. — Examination in the erect image when the eye exam- ined is hypermetropic, emmetropic, or myopic. In each figure three rays are shown emanating from a luminous point on the eye-ground. In hypermetropia they diverge after leaving the eye, in emmetropia they are parallel, in myopia they converge : /, the posterior focus ; H, prin- cipal plane of the dioptric system of the examined eye ; £e., observer. The ophthalmoscope is not shown. focal distance of 0.5 meter. If the distance of the far point is \ meter = 25 cm., the degree of myopia is four times as great = 4 diopters, and the correcting glass must 28 OPHTHALMOSCOPY. have a focal length of \ meter = 25 cm., etc. In the last case, for instance, the myopia is corrected by a concave lens of 4 D (with a focal distance of 25 cm.), because such a glass when held immediately in front of the eye renders parallel rays coming from infinity so divergent that they appear to come from the far point of the eye, which is at a distance of 25 cm. ; for a concave lens of 4 D lends such a degree of divergence to entering parallel rays of light that they seem to come from the focus of the lens {= 25 cm.). It follows, therefore, that the rays of light leaving a myopic eye converge to the far point. If, therefore, a normal eye is placed behind the ophthalmoscope it will not see anything of the eye-ground, since it is not focussed for converging rays of light, for converging rays do not occur in nature without a special cause. The examiner's eye, therefore, requires an additional lens behind the oph- thalmoscope of such a strength as completely to correct the myopia of the examined eye ; or, in other words, to render parallel the rays which emerge from the examined eye, since the normal eye is focussed for parallel rays of light. The degree of myopia of the examined eye can, therefore, be found in this way l)y selecting the weakest concave lens with which it is possible to get a distinct image of the fundus. The weakest concave lens must be selected so as to eliminate the examiner's own accommo- dation, for he could see quite distinctly with a stronger concave lens, because his power of accommodation would enable him to neutralize the excessive concavity of the lens. If the observer is myopic, he will need, in order clearly to see the fundus of another myopic person, a concave lens strong enough to correct both his own and the other's myopia. If, for example, he finds that a lens of 5 D is the weakest lens with which he can see the eye-ground clearly, and if he himself has a myopia of two diopters, the examined eye has a myopia of 3 D. If, on the other hand, the observer is hypermetropic EXAMINATION IN THE ERECT IMAGE. 29 to an extent, let us say, of two diopters and finds the correcting concave lens to be one of 5 D, he must add his own hypermetropia, and the patient's eye in that case has a myopia of 7 D. An emmetropic observer in this case would need a concave lens of 7 T>, but the hyper- metrope needs one of only 5 D, because his own correct- ing convex glass of 2 D neutralizes the effect of a con- cave glass of 2 D. He would also need — 7 if he looked through the ophthalmoscope with his own correcting lens of 2 D. But it is better to have only one lens behind the ophthalmoscope, hence he will need only — 5 instead of — 7 to correct the myopia of the examined eye. Measurement of the Hypermetropic Eye. Having now considered cases where the examined eye is either emmetropic or myopic, we must consider the possibility of its being hypermetropic. Again, we must consiclor how the rays of light emerge from an hypermetropic eye when it is illuminated with the ophthalmoscope. An hypermetropic eye without accom- modation is focussed neither for parallel nor for diver- gent, but for convergent rays of light (cf. Fig. B) ; that is to say, only convergent rays of light are collected on the retina to form a distinct image. Parallel rays of light entering the eye unite to form an image behind the retina at the point /, either because the axis of the hypermetropic eye is too short or because its refractive system is too weak, as, for instance, when the lens is absent. In either case the refractive system of the hy- permetropic eye is insufficient as compared with its axis, and therefore requires a re-enforcing lens. The hypermetropic eye can, by exerting its accommodation, increase its refractive power by increasing the refrac- •tion of the lens, so as to bring the image forward and on to the retina. It differs from the emmetropic eye in the fact that it has to accommodate even when looking into infinity, but this can be obviated by the use of a con- vex lens. As a rule, the visual error in the hyperme- 30 OPHTHALMOSCOPY. tropic eye is only partially corrected by a lens, the indi- vidnal correcting the remainder himself. In fact, it is impossible in yonthfiil snbjects, whose power of accom- modation is vigorous, to find the degree of hypermetropia by means of correcting lenses. Such persons always accommodate more or less when they fix an object, and they will accept only a convex glass which corrects a portion of their hypermetropia. This portion is called the manifest hypermetropia of the individual, while that portion which is corrected and concealed by the accom- modation is known as the latent hypermetropia. As the individual grows older and the poAver of accommodation diminishes, the manifest hypermetropia increases. If the accommodation is entirely removed, either by age or by a drug (atropin, homatropin), the total hypermetropia be- comes evident. The examination in the erect image furnishes a very convenient method of determining an individual's total hypermetropia without artificially paralyzing the accom- modation ; for if the hypermetrope, even though he be young, does not focus his eyes, but looks into the distance in the dark room, he will not accommodate during the examination with the ophthalmoscope, and the rays of light leaving the eye will follow the direction given them by the structure of the media ; that is to say, they diverge. The degree of divergence is proportional to the degree of hypermetropia and inversely proportional to the distance of the negative far point behind the eye. If the hyper- metropia is such that the eye is focussed only for rays which converge at a point 0.5 meter behind the principal plane of the eye, the error is corrected by a convex lens having a focal distance of 0.5 meter, or a lens of 2 D. The hypermetropia is 2 D. If in order to be collected on the retina the rays require a greater degree of convergence, for example, to a point only 25 cm. behind the principal plane of the eye ; in other words, if the far point is 25 cm. (— 1 meter) behind the eye, the error is twice as great. The hypermetropia is 4 D, and the correcting lens must EXAMINATION IN THE ERECT IMAGE, 31 be of equal strength, unless the individual when looking into infinity accommodates to the extent of 4 D. A lens of + 4 D held in front of such an eye will, there- fore, give to the rays coming from infinity the necessary degree of convergence ; for a convex lens of 4 D, held immediately in front of the eye, refracts parallel rays entering the eye in such a w^ay that they converge toward the focus of the lens — 25 cm., which is also the far point of the eye, as we may disregard the distance from the lens to the principal plane of the eye. ' // The same correcting lens will render the divergent rays '^< < o ^. 2 CO C Q p 'O O d f> ^ O c3 O ^ ^ 2.J:^ S.t^:| S-S fe = - 2f 2 S=^ J !=^ 2 O 03 CO "^ 0) !^ O) ^ be 3 C a; a> .- '^s 2 C ^ c^ >J OB ^ ^~' ^ ^ S8 ^ 2 '-^ ;2 M ^H 3 +^ o c3 ^ Vr,-r ---GO /11 c- c3 (V e- be bJC d ? (D 2 <^ 2 -t G ^- - » ^ i ^ C3 T* "^
  • £ 2H ^ ,03 bftCJ- 0) '53 03 > CONGENITAL DEFECTS. (Figs. 7-11.) Fig. 7. Congenital Circumscribed Defect of the Choroid (Coloboma Choroideae) in the lower part of the figure (erect image reduced to the size of the inverted image). The defect exposes the sclera and has a roundish out- line, its upper border being at a distance of three optic- nerve diameters from the papilla. Along this border a small amount of choroidal tissue is still present, but farther down the membrane is represented only by a few remnants in the form of pigment-spots and a few vessels. Some of the retinal ' vessels are seen on the surface of the coloboma. The rest of the eye-ground is normal. These defects of the choroid in the lower segment of the eye have been attributed to persistence and failure to unite of the fetal cleft. This explanation, though simple, is not quite adequate. The fetal cleft lies in the region of the optic vesi- cle, which later becomes the retina, but as a matter of fact the retina is not absent in the region of the coloboma, since both in this and in the following figure retinal vessels are seen traversing the coloboma. The defect is therefore not in the optic vesicle and its cleft, but in the region of the meso- derm or of its derivative — the choroid. These inferior colo- bomas and other congenital defects (cf. the following figures) are probably due in many cases to intra-uterine disease, and it is probable that the fetal cleft plays but a secondary role in the first group, consisting of inferior coloboma of the iris and choroid. Fig. 8, a. Congenital Circumscribed Defect of the Choroid and Malformation of the Optic Nerve (Coloboma Choroideae et Nervi Optici) (erect image reduced to the size of the inverted image). The choroidal defect in this case surrounds the optic nerve, which is much ^creased in size. The manner in which the vessels leave the optic disk is altogether abnormal. The optic nerve and the portion of the sclera joining it below are excavated (ectatic), the larger cavity containing three smaller diverticula, two oval and one round (staphylomata). A few retinal and choroidal vessels are seen in the region of the coloboma. Fig. 8, b. Congenital Defect of the Pigment-epithelium of the Retina in the Region of the Macula Lutea. — The two whitish patches correspond to defects of the choroidal tissue which expose the sclera. They are traversed by a few choroidal vessels. At the temporal border of the optic disk there is another defect of the choroid having the form of a triangle with the apex broken off. In the orange-colored areas, where the pigment-epithelium is absent, irregular lines of pigmentation are seen. The rest of the eye-ground is normal. The other eye shows similar changes. J^ The patient is a young woman suffering from hereditary syphilis. Fig. 8. 3 (q' crq ^ - - ^ B'3 c " ^ Sr O CO t" L_3 /iis QQ (p B^ <5 CO^^ Hj CD U-" /tn k^« "T* 1^ tn i-< O r3 -S CD "^ O (X> o o CD P ^P- 1- ro 2--^ 3 g I r-i Si,? —p-B - ^ O <^ C Hj fp c =3 ? B^ 2^^§^ 5-31-0 " * — ' fD ^J "^ o a- o 2- 500 p js- c« ct> rr 3 B p^ S g-g Vp "" ^ i ^.^- CO B (D r« O ^ »- S o t» (i*^ ? O o ^*^ SS'ot^O ,a 3 03^2 +2 g g «^ " S ^^^ ^ ''-< a a>;=5 fio3-C OJ.S^ =3 ii^l o) p ^|- 2 o I ^c^-^^ S >^'^ 1^ »H 'S rt ^^3 •=* 'S ^'3 ^ PJ , ^ =_- ,. ^ .. cu^^-^a'm fl o oj ^ 3 Ch^^.-H^t^o H- ■--^-s g O) o g^.^^ fl O g g 3 T^-^ 03 l|2 l-H-f §^^ 2^.5 ^^'^'^■^-api, g"^ bc^ ^-g to \ « =2 -« cJD 2 02 ffi -^ .5 ^ -^ g -S S « S5 '^ ^ M ^ o! 2 ^^ 1-^ vy >< ^ a b o3T3^o S d ®S ^^ d-^ ^ fl 9 fl-^ CJ g g P 05 P OS 08 -^ Sh ?s to Fig. 13, A. -Choked disc and macular clians^es, from a patient witli tumor tlie ci'rebellum (de >Sch\\einitzi. of P r; ■ o- PS =l;s.£.a°|el:-^r;?-s w B s. ^- ^ zL r, Q-- • '^ ^^ Z.. !x> O S-' - rt- S o >-• <^ tr»Td D- ►^ cT> 2 o ^"p-ti'l.?^ §^§^3^3 CB S SS" p^ P 5£ O B -a -. 5 g- Jr- -^ o^pPr^fD-i^^, Ico.qi^S^ ^ o- a ^ 2 e o^ ^ S*i^ f ^ B i ■ g-2.i^ 5'^ = '^ '^^ 5^ p ^ I M 2. ty* s:: ZL EL- B p tr -• ::: 2 2 5 Fig. 14, a. Horizontal Section of a Normal Macula Lutea, almost exactly through the fovea centralis (F. c). — The freshly- enucleated globe was immersed in a warm saturated bichlorid solution and hardened in alcohol. The sections were stained with hematoxylin and eosin. The walls of the excavation are probably not so steep in the living subject as they appear in this preparation. On the floor of the excavation the pigmen- tary layer is reduced to the slender cones with their fibers and nuclei. In the internuclear layer the fibers, owing to the manipulation of the specimen, diverge somewhat (better seen in Fig. 14, c), which makes the walls of the excavation appear steeper than normal. Magnified 14 times. Fig. 14, b, shows the outlines of the same preparation, seen under the same power as the following picture. Magni- fied 30 times. Fig. 14, c. Another section from the same specimen through the excavation and its surroundings, taking in the adjoining choroid and sclera, under a higher power than Fig. 14, a. (On the floor of the excavation there is a slight prominence which is an artefact.) Next to the pigment-epithelium we see the choriocapillaris. On the posterior surface of the sclera are seen several transverse and oblique sections of posterior ciliary vessels ( F.). Stain the same as in Fig. 14, a. The picture incidentally shows the relative thickness of the three membranes — retina, choroid, and sclera. Magnified 30 times. In both sections we see at the margin of the fovea centralis the internal limiting membrane (margo limitans internus), which in the specimen has become somewhat separated from its foundation. Corpus vitr. a Retina Corpus vitr. Ee. Retina ?^]mr -^i^^^ Sklera V V Fig. 14. V h .-•TV- a Retina Corpus vitreum E ^»':^-T~:/^ri-r^-fi' Nervus opticus J. „ Corp. vitr. i ft f'i liU'i' I' I- Fig. 15. Fig. 15, a. Longitudinal Section through the Papilla in Neuritis (Papillitis, Choked Disc), due to brain-tumor (sar- coma of the temporal lobe). — Stained with hematoxylin. The papilla in this specimen is moderately swollen. The swelling may be much more marked in these cases — even more marked than in the following picture. The separation of the retina from the choroid is an artefact. (See Ed. note opposite Fig. 13.) There is a heavy inflammatory infiltration (proliferation of nuclei) between the lamina cribrosa and the anterior sur- face of the papilla. In the subdural space (J.) occasional areas of inflammatory exudate (E.) are also seen. The trunk of the optic nerve, in the center of which a third segment of the central vessel is visible, is also the seat of moderately well-marked inflammatory proliferation. E., inflammatory exudate in the subdural space of the optic nerve ; J., subdural space ; B., retina. Magnified 14 times. In this case the papilla and surroundings first presented the picture seen in Fig. 12, a, and later that seen in Fig. 13,5. Fig. 15, b. Longitudinal Section through the Papilla in Neuritis and Papillitis from brain-tumor with purulent men- ingitis, terminating fatally in spite of trephining. — Stained with hematoxylin and eosin. The swelling of the papilla is greater than in the foregoing case and would be more pro- nounced were it not for the separation of the retina from the choroid (artefact). The lateral extension of the swelling beyond the border of the papilla, which in the ophthalmoscope produces the so- called enlargement of the papilla (see Figs. 13, 17, and 18), is clearly seen. We also see without difficulty a marked engorgement of the vessels, especially of the veins of the papilla (F. c.) and hemorrhages (H.) into the tissues of the papilla. There is also some inflammatory exudate in the subdural space. F. c, central vessels; E., exudate in the subdural space; Ch.y choroid ; i?., retina ; H., hemorrhages. ^lagnified 14 times. The ophthalmoscopic image in this case resembles that shown in Figs. 17 and 18. Fig. 16. Inflammation of the Optic Nerve and the Adja- cent Portion of the Retina in Syphilis (so-called Specific Neuroretinitis). — There is a marked blurring of the optic nerve and its surroundings, due in part to the diffuse central opacity of the vitreous. The peripheral portions of the eye- ground in this case are not diseased, but in many cases they are the seat of foci of disseminated choroiditis in various stages. The picture before us is characteristic, or at least strongly suggestive, of syphilis. The opacity may disappear under appropriate treatment, but usually leaves a more or less pronounced atrophic dis- coloration of the nerve. Minute foci of choroiditis may develop in the periphery in the course of the disease. V \ / y Fig. 16. Fig. 17. Fig. 17. Intense Inflammation of the Optic Nerve (Papil- litis) after meningitis caused by a blow on the head. — The inflammation in both eyes has led to marked infiltration of the tissues of the nerve, manifesting itself in grayish-white patches and striae on the papilla and surrounding portions of the retina, and in the hemorrhages at the lower outer border of the discolored areas. The diameter of the nerve is enlarged and the nerve itself moderately swollen and prominent. Owing to the presence of inflammatory product in the tissues of the nerve, the venous flow from the retina is impeded and the veins are therefore distended and tortuous (patient belonging to Prof. Eichhorst's clinic). The microscopic appearance corresponding to this picture would be about the same as that shown in Fig. 13, 6. 1 \A^ 1^' Fig. 18. Marked Inflammation and Congestion of tlie Optic Nerve in Orbital Tumor. — Exophthalmos (protrusion) was present. The intraocular extremity of the optic nerve shows marked inflammatory and edematous swelling in the picture. The inflammatory infiltration appears as a whitish striation. The veins of the retina are very much congested and numerous hemorrhages into the retina have occurred in consequence. The retinal arteries are moderately distended. S' 3 c a, g: a ^ ® S,^- ss ■» g. a. ><: » tr: fD $5 ^ «^ 3"*^ ^ 3-"s :=i^ s 2-^ 3".. 3«-=^^'^H^. mP (T) 3^ H-r ?^CD £-2- J^'h-.S-* 3-3-3- a.^^ -2^2 ^ ^'^^ ^ ^ O V 03 O) '^ s ^ OS'S S o <» o o a O CO ^ 02 -CJ ^ ^ a «« g ^ S3 33 > o a a « 03 -fj -^ ^^ s ^ ^ r- "* «-• a-^ ^ o a) o •^ o o OS ^_^ ^ ^-^ O oi fi '•+3 Sh c3 s-" 9 ? o Ph .2 o-^ b§ a o^ a S u o o 3 ^ o,^ a; o o !» -a OJ §.! O 53 22 o I ^ ^ a CO a 0) (M .2 03 fl a .2 .-^ '-2 50 g O ^ PJtH o a • pis > OJ O ^ 4) {zi S 03 S sh ., T^ a '^ ta 00 X ""i 03 ^ O e . -iS > ^ J-? 03 O o3 c3 -TS C3 CO • 03 •^-^-^ ^ Ph o3 a *^ 111 J O 5. . 03 ►>^ a tH r^ 03 >.H " =' o I? CO 1^ 3^ ^ a o a . -^J 03 03 ''' Pti '^ a3.2SH C QJ dJ o d> a c/ Corpus uitreum Sklera 'Veil. Arteria central. Vena centralis Neruus opticus Retina, Chor. Sklera Corp. vitr. j^jRetina ^■'- i~#^ Chorioidea Sklera ^^•^ Neruus opticus Fig. 21. Fig. 21, a. Longitudinal Section through the Entrance of the Optic Nerve in Partial Atrophy (of the Optic Nerve). — Staiued by Weigert's method, which colors the medullary sheaths a bluish-black. In the atrophic left half of the nerve-trunk the medullary sheaths are altogether absent. Owing to the partial atrophy and consequent diminution in the volume of the nerve, the subdural space is somewhat broader than normal and the arachnoidal sheath is plainly visible. The papilla is already distinctly flattened from atrophy. D., dural sheath ; A.^ arachnoidal sheath ; P., pial sheath ; V. cil.y ciliary vessel. Magnified 14 times. Fig. 21, h. Longitudinal Section through the Disk in Total Atrophy of the Optic Nerve, stained after Weigert. — All the medullary sheaths are wanting. The trunk of the nerve is thinner even than in the preceding case. The papilla shows a distinct atrophic excavation, on the floor of which the lamina cribrosa is laid bare. A portion of the arteria cen- tralis {A. c.) is seen in this section. This is the microscopic appearance that corresponds to the ophthalmoscopic picture shown in Fig. 20, h. The patient from which the specimen was taken presented at the time of his first examination a beginning gray atrophy like the pict- ure of Fig. 20, a, and later advanced gray discoloration of the papilla, as shown in Fig. 23. Later he developed pro- gressive paralysis and died in the insane asylum. The pos- terior half of the globe was kindly given me by Prof. Forel. Magnified 14 times. Fig. 22. Atrophy of the Optic Nerve due to Increased Intraocular Tension (Glaucoma). — The entire end of the nerve shows marked excavation and dark discoloration. The lamina cribrosa is pushed back and plainly visible owing to the disappearance of the nerve-fibers. The cho- roid near the optic nerve is atrophied and forms a pale areola, also known as the glaucomatous halo. The retinal vessels are sharply bent at the edge of the excavation and dip down to the floor, where some of them become visible on the lamina cribrosa. At first the veins are congested and dilated, but now the vessels of the retina are also beginning to atrophy. Parallactic dislocation and measurement in the erect image (see Introduction) reveals a distinct movement of the edge of the excavation in front of the floor, and the excavation is found to be about 2 mm. deep (6 D difference of refraction between the edge and the floor). The glaucomatous changes in the end of the nerve are illustrated in Fig. 24, c and d. V Fig. 22. s p I &§ -I 2-1;? S ^ 2§^a3g8p§|i2 oS. g|gp g^^S.S- ^2^.L_.X i S S-i i » o-g ETS o-S^ gg » 2 ^ ^ « 3-3 »-^. oS^S f|-. o^ ■-< 5 o o . P p v; P '^ o » C7- 1 2. ^ i» 5- 3, g- g^ p H p o ;5 ^ S 2 ^'l o s p (D <=> 2. o » P 2 ^ S P 3 S ^S. ^ ^^ o 3 ^ CD 03 P •-! o 3 -.= tzi ^^ S.S s2 g S-^ 3^^^a) _ B-sr. -o ^^►^ 3 a> ^.3 CO m CO O H a: m yo m H > a »> oa'L^a-crS-o - ? „ ^ p - ^• se c a. O) ? Q i" ■- c P 3 p p ^ p'o I -^^ a> < CO ^ a § B _ o a ^^. .-• cs 1^3 "2 sr a- ?r O (^ fD O OJ i- a- o s^ ''^ s: s. p. 'I i 3 o J.;^ o'o "5 3:^ CL'-^g ? a'a-g- ;i 5S-3*? "-^ tT-a gcrq Fig. 26, a. Section through the Retina in Retinitis Albn* minurica. — Stained with hematoxylin and eosin. The ravages produced by the disease will be at once seen by comparison with Fig. 3. Numerous hemorrhages stained red by the eosin occupy the anterior layers of the retina. In the internuclear (outer reticular) layer we find between the fibers numerous gaps formed by edema and exudation. In one spot (stained very dark) is seen a mass consisting prob- ably of fibrinous exudate (cf. Fig. 27). Similar gaps are seen in the nerve-fiber layer which con- tains numerous varicose nerve-fibers shown under a higher power in Fig. 26, b and c. Magnified 20 times. The section corresponds approximately to the ophthalmo- scopic pictures shown in Fig. 28, a and b. The white foci in the retina correspond anatomically to the masses of fibrinous exudate represented in Figs. 26 and 28, or to varicose nerve- fibers that are often aggregated in bundles, or possibly to collections of wandering leukocytes and tissue-cells in a more or less advanced stage of fatty degeneration. The fatty de- generation is not seen in the specimen, which, however, shows masses of emigrated lymph-corpuscles scattered here and there among the tissues. Fig. 26, b and c. Varicose Nerve-fibers from the section shown in Fig. 26, a, under a higher power. — Along the spindle-shaped thickenings of the nerve-fibers (stained violet by hematoxylin) are found nuclei of lymph-corpuscles or inflammatory leukocytes. Magnified 112 times. a ^ *«^.''«?V. •^-. rS^' «S ''^TO'*fiV/.-^>«,'-.- : . - *;!%'^":T'^^«f^i?'r^|i^^s^^. Fig. 26. M.l.i.-^ Pig.Epith. J. Sklera • V-. *., -^ ■■ •^ , f « 4 / • • . r '^'^^ Fig. 27. Fig. 27. Alterations in the Retina in Retinitis Albu- minnrica. — a represents a section through the retina, cho- roid, and part of the sclera. The interval between the layer of rods and cones and the pigment-epithelium, and the separation of the internal limiting membrane from the nerve-fiber layer are artefacts. b represents an adjoining portion of the same specimen. In the nerve-fiber layer and in the ganglion-cell layer leuko- cytes are seen scattered through the tissues, especially in Fig. 27, b. The lymph-spaces are wider than normal, owing to edema and the presence of amorphous exudate. The in- ternuclear (outer reticular) layer contains a network of tough fibrinous exudate stained red by eosin. In Fig. 27, 6, an amorphous fragment, similar to that shown in Fig. 26, is seen in the midst of the fibrin. The tissues of the internuclear (outer reticular) layer are likewise edematous (larger gaps in the tissue). The layer of rods and cones is degenerated and granular, the elements being widely scattered in places. The choroid is the seat of a pronounced inflammatory in- filtration (J.). The blood-vessel V., in Fig. 27, a, shows very little inflammatory thickening, in marked contrast to the blood-vessel F., in Fig. 27, c, the walls of which are greatly increased in thickness and contain pigment-granules. 1, Layer of nerve-fibers and ganglion-cells ; ^, inner retic- ular layer; 3, inner nuclear layer; 4, internuclear (outer reticular) layer ; 5, outer nuclear layer ; 6, layer of rods and cones ; 7, choroid ; 8, sclera. a and b magnified 122 times ; c, 150 times. &a;.= « ^J^-^^-^g^ -SrS^^g-3 «e> fl -is^^sh g j5 0.2'— ;:: §^ ^-M ^;. o_^i3.s w 1'^ §^= a ^i ^^iS)^|g§i.^^l^i'^ :^ ^^^ -^^^aJ^^^^-l.Saj 03, „-^ o a 9> 2 (Q tti B' a ^ O » m p f» w ^ 2.5 hj ^X ^*^ p- s f;© c ^. D- o e o " B S P Cr' i-K •-$ ja S. !1 ^ 05 2^^ 5 a .CD ^^^ . ^ o c 9. « ^ ^ ^ _ _ B "-J cc O CLP g-O g--.^ ^ W CD «n- rr- *■" J5 _ to B-H CO 3 G-:^^ Cfl -5 -e Fig. 31. Fig. 31. Changes in the Eye-ground in Pernicious Ane- mia. — The eye-ground is paler than normal. The disk is anemic and considerably lighter in color. The dilatation of the arteries is slight, that of the veins marked. The retina contains numerous hemorrhages ; some of them are pale in the center, which is rather characteristic of pernicious ane- mia, although it also occurs in other forms of retinal hemor- rhages. A few white patches are also seen near the optic nerve. The patient, who belonged to Prof. Eichhorst's clinic, died soon after the picture of the eye-ground was made. Fig. 67 shows a microscopic section of an area of the retina containing hemorrhages of this kind. Fig. 32. Obstruction of the Central Artery. — The edges of the optic disk are obscured by a thick white opacity of the retina, which extends over the entire region of the poste- rior pole. The vessels in the neighborhood of the optic nerve are indistinct in places as if they were interrupted, while in the macular region the minute retinal vessels appear espe- cially distinct. In the middle of the foveal region we see a cherry-red circular patch, not due to hemorrhage, but to a thinning of the retina, allowing the choroid to be seen through it, the red color being intensified by contrast with the white surroundings. The retinal arteries, which at first were contracted, have now regained their normal caliber fairly well, but they are still narrower than the veins. The blood-column in the arteries is interrupted in places. At the periphery the retina is normally transparent, so that the pig- mented inter vascular spaces of the choroid are plainly seen. The obstruction of the central artery, which is the cause of this ophthalmoscopic image, was formerly always attrib- uted to embolism. In my opinion the cause of the circulatory disturbance is much oftener thrombosis or obliterating endar- teritiSj embolism being very rare. o soQ-o ^^Bfo- Cri OBI « tf^ I o J5 B o ^ S- S- ^ L^^ ^S SSg=rp5oOc^^=---a> 3 2.»2. Fig. 39. Fig. 39. Pigmentary Degeneration of the Retina (Retin- itis Pigmentosa), Advanced Stage. — The color of the eye- ground is more gray or lead-colored, the pigment-patches are thicker, and in places form a regular network. The atrophic discoloration of the optic nerve is more marked and the ves- sels are smaller than in the last picture. This case illustrates the peculiar character of the visual disturbance in this dis- ease. The visual field becomes smaller and smaller and is finally reduced to a minimum as the disease progresses. As shown in the figure, the outermost zone of the retina remains free from pigmentation until this time. Accordingly, the defect in the visual field was a circular scotoma correspond- ing to the zone of pigmentation of the retina, showing that the retina loses its function wherever it is attacked by the disease. The pigmentation is probably a secondary process, as contraction of the visual field may occur without it. As the disease progresses the pigmentation spreads centrifu- gally and peripheral vision is also destroyed ; while, on the other hand, the centripetal advance of the process causes contraction of the central visual field. The anatomic changes of the later stage are shown in Fig. 46, c and d, where the enormous atroi)hy of the entire retina is nuich more conspicuous than in the ophthalmoscopic image. The section shows how the retina eventually becomes entirely converted into connective tissue and loses its normal transparency, explaining the gray appearance of the eye- ground in the severer forms of this disease. Fig. 40. Disease of the Eye-ground in Hereditary Syphilis. — This figure and the two following represent various forms of the same disease — hereditary syphilis — which, like the specific process in general, manifests itself in various forms. Whether the primary seat of the disease in these cases is in the retina (pigment-epithelium and rods and cones) or in the choroid, has not, in my opinion, been definitely established. I have inserted these pictures among the retinal diseases be- cause the pigment-patches appear to me to be situated for the most part in the retina, and because in some cases the disease shows a certain similarity to pigmentary degeneration of the retina which has just been described. The periphery in the lower left-hand portion of the picture presents a leaden hue and coal-black circular and triangular pigment-patches. The rest of the eye-ground is covered with minute yellow^ish-red spots. The yellowish-red roundish spots stand out from the brown dotted background, which looks as if it were sprinkled with snuflT. The retinal vessels are rather small and the optic Inerve somewhat discolored. I have chosen for this picture a case in which the disease was very well marked. Sometimes ;the sprinkling is found only in the periphery of the eye- ground, and is neither so well pronounced nor so extensive as in this picture. But whenever this sprinkling is at all well marked it indicates hereditary lues. A similar but much finer sprinkling of the eye-ground occurs in cases of insuf- ficient pigmentation (in blondes). The latter, however, is, as a rule, seen only by the direct method, while the luetic can be seen by the indirect method. Fig. 41. Alterations of the Eye-ground in Congenital Syphilis. — In this form, which is not quite so severe as that shown in the last picture, the disease is often confined for a long time to the periphery. In this disease also the pigment- patches are probably, for the most part, situated in the retina and are caused by a disease of the pigment-epithelium. I am unable to decide whether the pale linear and circular yellow- ish patches are situated in the choroid or in the pigment- epithelium. They may be situated in one or the other. This and the following form of the disease are not rarely found after a diffuse interstitial keratitis if, after the cornea has become sufficiently cleared up, the periphery of the eye- ground is carefully examined. In some cases the patches may be confined to one side, in others they may be scattered more or less over the entire eye-ground [and on both sides]. In the case here represented there had been a keratitis. The increased pigmentation at the margin of the optic disk, seen in Figs. 40-42, may not be present even when there is a chorioretinitis, and Antonellis's supposition that this marginal pigmentation (choroidal ring) is a stigma of hereditary syph- ilis is not quite correct. It occurs also in normal eyes. Fig. 42. Alteration of the Eye-ground in Congenital Syph- ilis. — In place of the black and gray patches, which predom- inate both in size and number in the foregoing picture, we find in some cases only whitish, also circular, and often con- fluent patches. The larger of these are undoubtedly situated in the choroid. This is shown in the figure by the oval white patch traversed by a red vessel. It is a choroidal vessel, hence the choroidal tissue near the vessel is absent and the white of the sclera shows through. There is no doubt, how- ever, that the pigment-epithelium of the retina has disap- peared at the site of the patches, and is slightly increased about their margins, so that the margins appear somewhat darker than the surrounding tissue. This condition also followed an attack of parenchymatous keratitis. Occasionally the forms shown in Figs. 41 and 42 are asso- ciated, resulting in a mixture of both dark and light circular confluent patches at the periphery, while sometimes, in addi- tion, we find the form shown in Fig. 40— viz., minute red and yellow spots on a brown, mottled background, with a sprink- ling of small pigment-patches. In general, these three types of hereditary specific eye- ground disease show a tendency to the formation of spherical foci, which coalesce and form irregular figures. Fig. 43. Fig. 43. Secondary Pigmentation of the Retina in Dis- seminated Choroiditis. — In the central portion the picture somewhat resembles pigmentary degeneration (Figs. 38 and 39). The optic nerve is somewhat pale, the vessels are small, the eye-ground lighter than normal, with a suggestion of yel- lowish-gray. This area also contains pigment-patches exactly- resembling those seen in pigmentary degeneration. In addi- tion, however, there are large white circular, sharply outlined patches near the periphery. They correspond to portions of the sclera which have become visible, because both the pig- ment-epithelium of the retina and, owing to the disseminated foci of inflammation in the choroid — choroiditis disseminata — the choroidal tissues have disappeared- Nothing remains of the latter except here and there a few isolated choroidal ves- sels, traversing the patches like narrow red ribbons. And even the vessels are wanting in many of these atrophic foci of the choroid. One of them contains at its center a small patch of pigment. This variety of chorioretinitis, a later stage of which is here represented, is often complicated with more or less opacity of the vitreous, and is frequently caused by syphilis. Secondary pigmentation of the retina also occurs after other forms of choroiditis if the inflammation is severe and lasts a long time, as will be shown in some of the later pictures. s •a «« ^ 2 "3 05 o .— .-H ;r5 S'^ -IS r-s.^ i? =« fl o '^ -T^ C rt IP "T o a> Hi 03 o BD n Tin 2 ^ o +j a; 3 > +^ e8 O 3 O O ijj ■=^5. 'S.t ^5|.§ii.- >^a «- O Q > c2 ce o o -^^rd ^1^ 2 ^ o *S 2 => 2 s « s s " S I -d .22 -g ^- .2 ® >» " 2 ® ® H >• 3 >j:S a * ® O rt O"^ ~ cc t» ^ CO o O 02 nS 2^-5 cS 03 c:8:|S-t az C3 "^ bV q; ^ s s o M o CO .2^'g o • -^ o OS G d ^ 02 P 0? « -S ^ Oh CO O "- ;=j oj 03 „, -Ci rv, C! Oh _rt -^^ ':> -^ O, . o 03 >>;=3 *Oh ^c!=^boco^2-*^ ,2^0. S^ '^S ^ 03 ^ ^1 .. . . O- CO bn.?^ Qj J-, -- •-- e -» bO . ^ bO Fig. 45. Fig. 45. Disease of the Macula Lutea of the Retina resulting from a High Grade of Myopia. — At a one sees the reddening and slight swelling of the nasal portion of the nerve that are apt to develop when eyes of this kind are subjected to strain, and which probably represent a func- tional hyperemia, although they are regarded by some as inflammatory conditions. The disk also is somewhat oblique and surrounded by an atrophied portion of the choroid in the form of a " meniscus " or cone. The pigmentation of the eye- ground is somewhat ftiinter than normal. The macular dis- ease manifests itself in yellowish-red spots and a somewhat irregular pigmentation. The middle of the fovea is occupied by a black spot surrounded by small hemorrhages. Fig. 45, h, represents a more advanced stage of the disease, recognized by an increase in the pigmentation and the pres- ence of white spots, which indicate that the choroid is involved and atrophied in places, exposing the sclera. A few pale spots extend as far as the atrophic meniscus about the optic nerve. Fig. 45, c, shows an advanced case of macular disease, in which there is not the slightest doubt of the choroid being involved. The optic nerve is surrounded by an atrophic ring which is broadest on the side near the macula. The macular region is occupied by a large white patch with sinuous and partly pigmented outlines within which the choroid has entirely disappeared, except for a few vessels and traces of pigment. To the temporal side of this the choroid and retina have disappeared, leaving a large atrophic patch extending as far as the equator, covered with irregular masses of pigment. Fig. 46. a. Secondary Pigmentation of tlie Retina caused by a Fragment of Percussion-cap (not shown in the picture), which remained in the eye twenty years. — Posterior segment of the eye seen from the frout. At the center one sees the optic nerve and the retinal vessels radiating in all directions. In the left half of the figure the retina is detached from its base, but whether this condition was present during the indi- vidual's life, or is an artificial product, cannot be determined. The area of retinal detachment shows the pigmentation which closely resembles that seen in pigmentary degeneration (retin- itis pigmentosa, see Figs. 38 and 3D) better than the rest of the eye-ground. This preparation shows more advanced changes in the retina than are seen in the ophthalmoscopic picture in Fig. 74, which also shows the changes produced in the eye by a piece of percussion-cap. The patient, who was recently examined, now shows much more marked pigmenta- tion of the retina than at the time this picture was taken. Fig. 46, h. Sagittal Section of an Eye with a Total or Funnel-shaped Retinal Detachment of Long Standing. — The retina extends forward in the form of a band, which is broader in front, still contains some remains of the degenerated vit- reous body, and surrounds the lens. The interval between the retina and the choroid is occupied by an amorphous exudate. Fig. 46, c. Pigmentary Degeneration of the Retina (Retin- itis Pigmentosa). — This picture represents an advanced stage of the disease, hence the normal structure of the retina is entirely lost, being represented by a fibrous membrane con- taining many nuclei interspersed with pigment. The rods and cones have disappeared completely. The choroid is normal. Magnified 30 times. Fig. 46, d. A Portion of the Same Specimen under a Higher Power. — In places the pigment is collected about the blood- vessels in accordance with what we see in the ophthalmoscopic image : P.P., pigment in the retina. Magnified 78 times. Retina Nero, optic. ^L b Chop. Retina Corpus vitreum Retina. «HV -?3s«i^. 1 Sklera d Fig. 46. 5" Cbs ^o o fl> EL 5' 5^ ?e S B P _ :S! S «^ &. Zt S' cr"T:! « r^ X^ -» B'^ ^ft> s-5. P ►^ s. p p 3 o.^ •• ^.P^p ^ S S 2 ^-r^^^ o ;< P ^' CD ^ p' ^^ o — 2 p •'J -' ►^ <^ n "" 5 ^-w-. >_^c _.o ^p CL.^.^ ^ P ^^ ^ o ^ ►-• cj^ a- "-^s (X, ^ - O^P^i-O'"-,- g 3 s- c« r- - =• ^ ^ ^ <^ f2 O CD ^ B-% ic^ r:3:^ '^ ^p C m t^ «^ $5 «= » CD CD 2] 3 !^ <^ ft) c n> - 2"^ ^' ^ w ^ i-h P-i ,^3^ g :. 3-?^S? ;. ;;« c= ^ ET a. Cl. g CO H ^ a 2 »2' fj; a clS"^ (t <; ^ O) (D •-< g 3:^ ^- cb 2- 3 « B cr Hj j^ >< Pi 2. S". o a> ^(t. p p X- :t-; CD p d. a d i^ S O o) e ^ g- -^ g Crti<- o S O &-CLB r/3 ;r2'-< Ct> "-^P "TCD OCT? O v3 en CD ^ -P 6 5 >» O Q^ ^, ^ pC f^ S2 S O 03 =3 o o -^ b"3 >-.-^ C^ " cp > 2 «+:; 03 O a ^ - '^ - " he . ri (» oj >^n3 <3^ rrt sh ^ S S 3 S S S 2 g ^ U S o c »-• d -, ^ 5 -^ ni o g'^ OJ P^t>^, ^ c3 Qj tc c3 '^ 5- OP O 02 ''^ 5 CC !» o 03 □ '-I 10 e '-'^ 1^ 2 fl 5 (« ^ s^ QJ O .2*^ c ^ ^ ^ ^ t: s ^ S o O 03 ^rO ^ js OP 5 oj >• ^ a "tS N P SVi o S 5 a o ^1^ a a fl"E-l S3 <^ '3^ S^§ H CO ;-! c3 o3 a ^ o CO .^g^ 3 - ^ _ a ■♦^.s^ be a a 2^ C 03 ^ ^ j: o 3 ^ p^ '- '^ t. -in fl S 5 22 CO "^ 3 ^ W 03 n3 c3 ^ CO P^.!S -)-3 -tJ O .^-J 03 g _ .a-S-s I a p \ / \ \ ego- - » ^ I ^-^ |^|-s=^ |- |-3 tr en 3gc:;-g'^5iSg35^a5fO § » 8 § o 1=^^^ 1^ §^^ ? S* p «^ Fig. 56. Air-bubble in the Upper Portion of the Vitre- ous due to tlie entrance of an iron splinter (direct method, reduced). — The accident occurred shortly before the picture was made, while the patient was working with iron, and the splinter became embedded in the lower part of the retina. Its entrance was followed by the formation of an air-bubble which disappeared after a few hours. These air-bubbles always disappear very rapidly, so that they can only be seen immediately after the injury. Several air-bubbles of this kind may be found in the vitreous body after the entrance of a splinter. Hence air in the vitreous is an important diagnostic point, indicating a foreign body in the eyeball. Occasionally, although rarely, the mere injury of the eye by a splinter may, without its remaining in the eye, be followed by the entrance of air into the vitreous, so that the finding of such an air-bubble does not positively indicate the presence of a splinter in the eye. Air-bubbles in the vitreous look like air-bubbles in a microscopic section. In this case the splinter was immediately removed by means of the author's large magnet, whereupon the wound rapidly healed and vision was completely restored. For further details about my method of operating with the magnet, the reader is referred to Haab's Atlas and Epitome of Operative Ophthalmology. Fig. 56. Fig. 57. Fig. 57. Old Injury of the Retina by an Iron Splinter.— In the two cases shown in the foregoing figure, the foreign bodies had been only a short time in the retina and either lay apparent on the surface or were embedded within the membrane ; the present figure shows two cases in which the splinters had penetrated the eye some time before and now present a somewhat diflTerent picture. The foreign bodies are here covered by a whitish exudate, the black color of the metal showing only in two places in a. In the latter the splinter, which had been almost two months in the retina, produced a characteristic alteration in the immediate neigh- borhood. The pigment-epithelium has in part disappeared and the splinter is surrounded by a light colored areola in which a few choroidal vessels are seen. This areola also shows an irregular pigmentation, which becomes more intense near the foreign body. In the adjacent region there are three small choroiditic foci, light in color, with ill-defined edges, and surrounded by irregular pigmentation. In b there are no changes in the^ immediate surrounding of the splinter, although at the time the picture was made the splinter had been in the retina six weeks. (For further details concerning this case, see Hiirzeler, loc. city B, case 4.) '^ ^Hmz^ Its'. g|:-^il" .S-J-g^^-2 » 5»«i5 A ° 5-2 « Ci_i '^Oojf-i^rOO'^a: 53 vr_- i, a:) ' Fig. 58.1. I g S^-H: Ji S.i^ ^ g S. l;^ g. I B B e:"^ ? 2. g, - s 4-1 CD ft> ^ tf (^ t3-^^ n> g S-^ o e 2 e o a> »-< CD Fig. 59. Retinal Detachment in the Temporal Portion of the Eye-ground. — Although the injury is one of about twelve weeks' standing, it may be called a recent injury, as there is not as yet any marked degree of opacity or wrinkling of the retina. The picture of the retinal detachment shows one important phenomenon, namely, th e ab s ence of the roidal striations in^jiL&^-detai^hed -fti'e ar''ttTe striations being obscured by tlie slight opacity of the retina, as also by the subretinal fluid. In the marginal zone of the macula, where the retina is thickest, the opacity is most marked, so that the central depression, which is the thinnest portion, appears more fright red by mn||-nj;t.- on the other hand, the red color ^//^ 01 tne choroid shines through more distinctly than in other kinds of macular opacities, because the retina is thin in the 1 '^ region of the fovea on account of the atrophy of its elements. ^^^^"^"^ Occasionally, after the retinal detachment has lasted for some time, an actual perforation may even be observed in the center of the fovea. The detachment, which in this case occupies the temporal quadrant of the eye-ground, is quite superficial — that is to say, not very far removed from the choroid. In the macular region there is an hypermetropia of 4.0 D ; toward the periph- ery the hypermetropia is 7 to 8.0 D, while at the papilla the eye is emmetropic. Vision is reduced to power of counting the fingers at a distance of 3 meters. Fig. 60. Fig. 60. Retinal Bands and Retinal Detachment after a Punctured Wound of the Eye. — Four years after an insig- nificant injury of the eye from a sharp piece of tin, which had pierced the sclera to the temporal side of the cornea, vision began to deteriorate. As the picture shows, there was a grayish-white exudate, spherical in shape, in the outer and upper portion between the corneal border and the equator, projecting some distance into the vitreous, seen in the picture at the left lower border. Below this exudate, which occu- pied the site of the puncture (and touching it above in the picture), the retina was detached, and this detachment ex- tends some distance along the upper border. Wherever the retina is detached the color is paler, and we see folds and irregular tortuous vessels somewhat darker in color than the other vessels in the picture. Between the detachment (in the lower portion of the eye) and the exudate are a number of white bands or lines, some of which anastomose, although in the main they run in the same general direction. In the portion occupied by these lines there is no retinal detachment. I am unable to determine whether these bands are of the same character as those shown in Fig. 58, b. For weeks they showed no change. The macular region presented abnor- mally heavy, somewhat irregular pigmentation. The retinal detachment is likely to increase as time goes on. Fig. 61. Retinal Detachment at the Inner Upper and Inner Lower Portion of the Right Eye (indirect method). — At the inner upper portion there is a slight tear in the detachment through which the red color of the choroid is seen. Toward the nasal side there is a strip of retina that has not yet become detached. Above and below this strip the detachment is quite marked (the detachment became even greater later on, in spite of treatment). In this case the detachment which had existed for three months appeared quite suddenly. Both eyes had been oper- ated on thirty-five years before for lamellar or congenital cataract ; in the left eye the pupil was cloudy, but the right eye had fairly good vision up to the present time in spite of the aphakia. From the presence of a fine band in the ante- rior portion of the vitreous, wliich otherwise is quite clear, it may be suspected that an injury of the vitreous with pro- lapse occurred at the time of the operation. This case shows excellently the great danger of injury of the vitreous, and that the retinal detachment which it produces may, under certain circumstances, be greatly delayed — in this case thirty-five years. Fig. 62. Fig. 62. Retinal Detachment fSolutio Retinae) with Laceration. — It is not uncommon to find in retinal detach- ments a tear or hole of varying size and shape in the detached portion of the retina. The opening is quite often surrounded by a shred of the membrane of a corresponding outline, which appears to have been torn out, and then reflected or puckered. In the present case the tongue-shaped i)ortion of retina ex- tending from the lower margin of the picture toward the red, approximately quadrangular opening, in the detached portion of which it forms the lower border, was probably torn out of the detachment, and thus produced the opening. According to Leber, the vitreous as it shrinks strips the retina from the pigment-epithelium and occasionally produces an opening cor- responding to a spot where it is more firmly attached to the retina. Through the opening, the edges of which are some- what reflected, we see the choroid with its vascular striation, which is very pronounced above, where the retina is normal and transparent. Toward the left in the picture the detachment is beginning to spread. At this point it is quite superficial. The optic nerve is invisible, being behind the retinal detach- ment. Fig. 63. Hemorrhagic Retinitis of Pregnancy. — In spite of the presence of the stellate figure in the macular region, no albumin was found in repeated examinations of the urine. After the woman's delivery at term, the disease, which affected the left eye, subsided spontaneously within three weeks. The entire mass of hemorrhages and white degenerated patches seen in the picture disappeared completely, although the woman was extremely anemic both before and after her delivery. Vision also was completely restored. The right eye was not affected. It may be that we have to deal with an incomplete thrombosis of the central vein, which only partially occluded the lumen of the vessel. » ; ^ > 77 ,fJ'\,''.\ Fig. 64. Retinitis Circinata (recently described and named by Fuchs), seen in the right eye of an otherwise healthy man seventy-seven years of age, whose other eye was normal. — A number of isolated and coalescent, glistening white patches, closely resembling in color those seen in albuminuric retinitis and diabetes, are grouped about the macula in the form of an oval. At the broadest portion of this girdle surrounding the macula are a number of isolated whitish patches and dots, some of which resemble crystals. Here and there within or among the white patches are small round hemorrhages. The [white patches are traversed by the retinal vessels, which lusually do not show any changes in the ophthalmoscopic image in this disease. The macular region is slightly opaque and the foveal reflex is absent. As vision is only one-fiftieth, it may be assumed that marked signs of macular disease would otherwise appear in the microscopic image. A little to one side of the center of the fovea are a few pale patches and one dark spot which occupies the pigment-epithelium. In other cases marked changes were observed in the macular region, consisting of yellowish-gray or yellow, irregular, washed-out patches. The rest of the eye-ground is normal. At the temporal border of the papilla there is a narrow sickle, although there is no myopia. Fig. 65. Changes in the Eye-ground in Leukemia. — The case is one of splenomedullary leukemia with enormous splenic enlargement in a young patient of Prof. Eichhorst. The disease began about a year and a half ago. The patient does not as yet complain of any visual impairment. Although the number of leukocytes is greatly augmented, the eye-ground is not paler than normal ; in fact, there are at the periphery a number of darker patches due to increased pigmentation. The most conspicuous feature is that the arteries and veius of the retina have the same color- ing, the veins being only recognized by their tortuosity, which is excessive, and their increased diameter. The color of the retinal vessels is almost white, this being due in part, no doubt, to the pale color of the blood, but more particularly to changes in the vessel-walls, especially at the periphery, where we observe minute light and dark dots and a few larger pale patches ; also two hemorrhages with pale centers. Round the optic nerve and the macula the retina is slightly opaque. The papilla is cloudy and paler than normal and its outlines are obscured. The changes are about equally marked in both eyes. Fig. 66. Glioma of the Retina. — The picture was taken from a boy two and a half years of age, who came to me with advanced gliomatous proliferation in the left eye. A careful examination of the right eye revealed in the nasal portion of the eye-ground a small glioma, appearing as an oval grayish nodule with a rounded thou^h^omewhat irreg- ular surface. The growth was sharply^^tlined and the surrounding tissues showed no changes. The rest of the eye- ground was quite normal, the pigmentation is not marked, and the choroidal vessels are plainly seen. Although this nodule grew very slowly, the neoplasm in the other eye prob- ably spread to the brain, so that death ensued at the age of three and a half years. Fig. 67, a, explains the ophthalmoscopic picture of the Retina in Pernicious Anemia portrayed in Fig. 31. — The figure shows a small portion of the retina in transverse sec- tion containing the hemorrhages colored a bright red with eosin, especially in the anterior layers of the retina. They are especially plentiful round the blood-vessel F, where there is also a slight hemorrhage in the internuclear (outer reticular) layer. Magnified 90 times. Fig. 67, h. Small Inflammatory Focus in Disseminated Choroiditis (superficial view). — The choroidal vessels seen in Fig. 70 do not appear in this picture. On the other hand, owing to the high power, the variegated form of the pigment- cells of the choroid and the nuclei of the cells which compose the infiltrate can be made out. The picture was taken from a thin longitudinal section of the choroid. Magnified 112 times. Corpus Ditreum Haemorrhag. ^ Chorioidea a Haemorrhag . :V--.-.««||^,^,... I \1^ V,--." Fig. 67. .Td .Bi"^ i 9 4- l-C Fig. 68. DISEASES OF THE CHOROID. (Figs. 68-86.) Fig. 68. Recent Disseminated Choroiditis.— Inflammatory foci in the choroid are recognized in the main by the fact that they are traversed by the retinal vessels. In the early stages they appear either yellowish-white or grayish-white with ill-defined outlines. The condition is soon complicated by changes in the pigment and the margins of the foci become dark, or else the center appears more deeply colored. In addition to the pale foci there may be a greater or lesser number of darkly pigmented patches which may have any j shape. In the case before us we have to deal with the common [variety where the foci in the choroid are circular in outline. These patches may coalesce and thus form oblong and irreg- ular patches. With the exception of a few at the upper border of the figure, which already show a dark border, all the foci in this case are recent, as we see by the haziness of the outlines and the yellowish-gray or yellowish-red color. The nasal half of the optic nerve is somewhat reddened and the veins of the retina are slightly more engorged than usual. Foci of this kind, as a rule, tend to become converted into white patches, owing to atrophy of the choroid, which allows the sclera to shine through. Proliferation of the pigment, as a rule, is superadded, as we see in the upper portion of the picture and especially in the next figure. The inflammation is due to accumulations of round cells, the surface view of which is shown in Figs, 67, 6, and 70, and a transverse view in Fig. 79, a. The latter figure also shows, in addition, the subsequent anatomic changes that occur in this form of inflammation. .2 tic?- ^MC^-S^^ I •3 ^ § s:5.3 I «.H ^^ a 5 s .2 S|.gJ § £ « S^l'B^iS.M'?^- «, 2 ^ +2 G :i v^,::: 2 -^ c3 ^ rr, tu ?^ '^ OQ 2 CO >»ri -^ "^^ >; -M i-J -^ ?< ^^ O o •■-"P-i!:3_i*'cc_Q.£OoCaiai Jr^ ^ aj-^:S a- M ^- .^--l-^ ^ -^ ^ ^ ^ "^ o.i: ^S :S ^ .= ^_^ o cS o (if 2 K^ s!h o ?t^ ^ -S 9 ^ a .. ^cuc35::;j:2c3go^aS«i^°3P£ l|l3 = i| = °2i|.i|J| e8o3fl^ajcot>,a3 o^rOtS-'^^O-McS >a3"^^fe_S2G -2 ^ d 5R '^ "tS -^^ a h>"^ o ^ ^iiocL'3 ii-'HtB.Ci-irii;-!"^ 2 S ^ 5?^^-^ P. *3o.S ^^^ g o :5^ ^ Dnrg '^O^^gfl^-g'Sa) W J-, Kfi"^ Qh O eS -tS O ^ Q^ Sh '—* g-B §J.2-g «^ >,« g - S s CX2 ^i±- &x)^.2 ^^ S i=^-S ^ a a o r^ (T< -+-' ^ :L r^ <_> ^^-H i-H ^v, ,P ^ ai O -^. _C ,^> >H 03^3 3 ^p=5 -?^ . ^05-^ gg^^c3o3^^0 .-^E.flc^'^cS ?. CU 3 ^^ ^ .2 .S ^ fl ^ ^ -S p Fig. 72. Fig. 72, a. Hyaline Bodies (Drusen) in the Vitreous Layer of the Choroid. — The patient, a womau sixty-one years of age, had the same condition in the eye-ground of the other eye, although vision was normal on both sides. The patches are recognized as drusen of the vitreous layer by their position behind the retinal vessels, their yellowish-white, somewhat shining color, and their somewhat circular outline. They are usually found in the neighborhood of the papilla. The anatomic appearance of these structures is shown in Fig. 82, a. Fig. 72, b. Senile Pigmentation of the Retina. — The pict- ure was taken from a man seventy-six years old, who, like many persons of advanced age, showed pigmentation at the periphery of the retina in both eyes. The pigmented patches appear in the form of fine dots irregularly distributed or in the form of lines frequently forming more or less distinct pentagons and hexagons. I have seen these peculiar figures in other similar cases. The visual field in this man was normal as regards the external borders, though there was some contraction of the color-field. There was no nyctalopia. Visual acuity was impaired by beginning cataract. It may, however, be quite good in spite of the retinal pigmentation, as the central portion of the retina usually escapes. It is not uncommon to find drusen of the vitreous layer in combination with this form of retinal disease. The pentagonal and hexagonal figures may possibly be ex- plained by assuming that each figure contained within the dark dotted lines corresponds to a vascular or lymphatic nutritional region belonging to the retina or choroid, although this requires verification by more accurate anatomic study. This senile pigmentation more frequently appears in the form of irregular figures and patches, as shown in the upper right-hand portion of the picture. >^ i—^ '^ ni tj ^^ _rt rr OS S-i _ ,-s CJ "T II lr.^11 lin l»!ll -'I ^ a> e.'^ Sis ^ ^.^^ So 001— I.SoOO+Jf^d "taM ««t-i+al-HCC0Sc303^ Fig. 74. Fig. 74. Chronic Disseminated Choroiditis and Secondary Pigmentation of the Retina due to the Presence in the Eye of a Particle of a Metal Cap (direct method). — While the child was pounding metal caps a small piece of copper pene- trated the sclera of the right eye, close to the inner corneal margin, and became surrounded by an exudate in the form of a grayish-white hemispheric muss (like the one seen in Fig. 60), projecting outward and downward in front of the equator into the anterior portion of the vitreous. In the neighborhood of the exudate a retinal detachment occurred which later disappeared. Then the exudate surrounding the foreign body became diminished in size. For a long time, however, a linear patch of exudate was seen passing through the vitreous toward the optic nerve. The exudate itself and the linear patch are seen in the lower right-hand portion of the picture, which was made a year and a half after the injury. In the meantime a number of patches, ranging in color from yellowish-red to black, appeared over the entire visible portion of the eye-ground, especially in the inner lower quadrant. Immediately after the receipt of the injury a slight optic neuritis, and later a macular disease in the form of minute dotting (shown in Fig. 53, b), made their appearance. At the time the picture was taken the optic nerve had some- what regained its normal condition, but the macula still showed marked changes, especially the dotting at the periphery. The pigment-patches resemble those seen in pigmentary degenera- tion of the retina, and probably lie for the most part within that membrane. During the twenty years following the injury the pigmenta- tion of the retina increased considerably, especially at the periphery. Vision is still i. This pigmentary degeneration is also shown in Fig. 46, o, which was taken from a similar case. Fig. 75. Miliary Tubercles in the Choroid in Acute Mili- ary Tuberculosis, an appearance not rarely seen in this disease shortly before death. — The circular patches, some of which tend to coalesce, are not sharply defined and, while they are small and still partially covered by pigment- epithelium, show gradations in color from grayish-white to yellowish-white and, finally, yellowish-red. The larger nod- ules occasionally project somewhat and force the retina outward, so that they impart a corresponding bend to any retinal vessel that may pass over them. Miliary tubercles are often difiicult to distinguish from the lesions of dissem- inated choroiditis, as, for instance, the form shown in Fig. 68. The anatomic features of this disease of the choroid are more fully shown in the transverse sections of Fig. 82, b and c. Fig. 76. "^^^-^ Fig. 76. Chronic Tuberculosis of the Choroid (direct method). — The tuberculous proliferation, consisting of a great number of closely aggregated tubercle-nodules — so-called conglobate tubercles — forms a slowly growing tumor which, even with the ophthalmoscope, is seen to be composed of grayish-red nodules. The tumor lies at the upper portion near the periphery ; its anterior border cannot be seen with the ophthalmoscope, while its posterior border is surrounded by an irregular and ill-defined pale border of choroid which is of some diagnostic importance, as it shows inflammation and corresponding loosening of the pigment. In addition, a number of small disseminated white and yellow choroiditic spots are seen near the edge of the border, giving one the distinct impression that the tumor is setting up inflammation in its immediate neighborhood, a phenomenon which is con- stantly observed in tuberculous proliferations and distinguishes tEern from sarcomaTloFinstance. We also see that the optic nerve is inflamed, that is to say, reddened, and not sharply outlined, although this may be due to the fact that the boy was suffering from a complication of conglobate tubercles and miliary tuberculosis of the brain. (This case, in which my teacher [Horner] for the first time diagnosed conglobate tubercles of the choroid in man with the ophthalmoscope, I have described more in detail, both clinically and anatom- ically, in Grafe's Archiv, vol. xxv.). Fig. 77. Sarcoma of the Choroid.— The round, bluish-gray tumor with a somewhat mottled surface, seen in the left half of the picture, projected into the vitreous from the region of the equator and obscured one-half of the optic nerve. In examining by the direct method, if the surgeon moves his head to and fro, he will see the edge of the tumor being pushed over toward the optic nerve, showing that the edge of the neoplasm does not lie upon the optic nerve, but at some distance in front of it, corre- sponding to the curve of the roundish nodule. The neoplasm is covered by the retina, as we see by the vessels which traverse it. The course of the vessels differs somewhat from that in the normal retina, being slightly more tortuous. The sarcomatous nature of the tumor is recog- nized by the dark color of the entire mass and the somewhat fainter mottling of the surface. A simple detachment of the retina would pre- /sent folds. At the lower border of the picture there is a simple retinal detachment such as frequently accompanies tumors of this kind. The rest of the eye-ground is normal. In both this and the following case we have to deal with a pigmented sarcoma. Fig. 83 shows the anatomic relations of this important form of tumor, which must be differentiated from chronic tubercular proliferation (see remarks accompanying Fig. 76) and from glioma of the retina. The latter tumor is rarely seen with the ophthalmoscope (see Fig. 64, h). It has no pigment and its surface frequently presents hemorrhages. It occurs only in youthful individuals, while sarcoma of the choroid, on the other hand, is rarely seen before the twelfth year. A (moderately pigmented) choroidal sarcoma may be simulated by an invagination of the globe by a tumor growing on the outside. This may occur when the tumor presses upon the side of the eyeball, and thus gradually causes the wall to bulge in the equatorial region, without penetrating into the interior of the eyeball. I have known this to happen in two cases of carcinoma in the anterior portion of the orbit, originating from the upper jaw and the cavity of the nose. Finally, sarcoma must be differentiated from the so-called phantom tumors which probably originate in the retina and produce one or more spherical prominences in the anterior portion of the bulb. They are probably due to cysts produced by senile degeneration of the retina, for they not infrequently disappear in a short time without leaving a trace. They are usually seen by direct inspection or, after the pupil has been dilated, by lateral illumination. Fig. 78. Sarcoma of the Choroid. — In this case the pig- mented mass is considerably larger than in the previous one. The tumor is hemispheric and the posterior border nearest the optic nerve is not seen, because it is obscured by the overhanging portion of the neoplasm. Hence the retinal vessels disappear for a time and reappear again on the surface of the tumor, where their course is irregular. The pigmenta- tion of this tumor is a little less intense, and it therefore appears paler than the one in the preceding figure. Fig. 79, a. Recent Disseminated Choroiditis.— The areas of infiltration iJJ) seen here in transverse section, instead of from above, as in Figs. 67 and 70, lie between, and iu some cases in front of, the vessels which are also seen in transverse section, and are partially filled with blood. Fig. 79, b. Later stage of the disease when the retina is involved, that is to say, has already undergone connective-tissue degeneration wherever it comes in contact with a choroidal focus, and thus becomes involved in the disease. In places the retina is reduced to a mere connective-tissue membrane into which the pigment from the pigment-epithelium is begin- ning to penetrate. The latter is engaged in proliferation ; some of the cells have lost their pigment and iu some places the epithelium has entirely disappeared. Underneath, throughout the entire preparation, the vitreous layer of the choroid (L. r.) is seen. In the choroid we gee a few blood-vessels filled with blood, in transverse and longitudinal sec- tion. On the whole, however, the growth of connective tissue and scar- tissue is indicated by the fact that the vessels and the pigment are less prominent iu certain places. ,The round-celled infiltration at J is the result of an exacerbation in the inflammatory process. In some places the retina and choroid are evidently adherent: the open spaces between these adhesions, which w'ere in part filled with exudate and pigment, have, for the most part, lost their contents iu the preparation. Fig. 79, c. In this preparation we do not see any recent inflammatory infiltrations. The retina and choroid are thinned, closely adherent, and reduced to mere cicatricial tissue. In places the pigment-epithelium has uudergone marked proliferation and projects into the retina (second- ary degeneration of the retina, cf. Fig. 43). In other places the pigment- epithelium is altogether wanting. In the choroid almost all the vessels have disappeared and the pigment is present only in places. Wherever the pigment and the pigment-epithelium overlying it are wanting (as, for instance, at the left extremity of the figure), the sclera shines through and thus forms the white spots characteristic of disseminated choroiditis, while the accumulations of pigment (P) produce the black spots seen in the ophthalmoscopic image. The three figures are magnified 78 times. Retina J. J- Sklera L.v. Corp. vitr. Corp.vitr. Fig. 79. Fig. 80. Changes in the Choroid due to Violent Contu- sion of the Eye ; Lacerations of the Choroid. — The eye was severely contused by the paper wadding from a blank cartridge. After the blood which had been poured out into the anterior chamber and into the vitreous disappeared, a large area to the nasal and lower side of the optic nerve and half of the nerve itself were seen to be covered by a whitish membrane, evidently consisting of connective tissue, completely obscuring the retinal vessels and the borders of the optic nerve, as shown in the figure. The outline of this membrane consists of a series of bizarre curves and in places is edged with black. To the nasal side there are five variously sized linear lacera- tions in the choroid, characteristically arranged in concentric curves parallel with the equator, their white color being due to the fact that the sclera shows through the tears in the choroid. They are sharply outlined and in places slightly edged with black. The retinal vessels continue their course over the lacerations without interruption. The area between the optic nerve and the macula is finely dotted. The rest of the eye-ground is normal. ^>fc*^i ^ H^J^^^~~ t C^/'-^ r^t^i^^ /f'- FiG. 81. Sclerosis of the Choroidal Vessels; Disseminated Choroiditis and Secondary Pigmentation of the Retina.— This figure is taken from an unusually well-developed case, though we not infrequently see much less pronounced ex- amples in which the alterations are confined to a small portion of the eye-ground. The most important features of the disease are the arteriosclerosis of the choroidal vessels and the atrophy of the retinal pigment, so that the choroid becomes very distinct and the choroidal vessels, the walls of which become white and opaque, appear almost white on a dark background, instead of presenting the usual appear- ance of a red vascular plexus. These changes in the blood- vessels are most marked at the anterior pole around the optic nerve and gradually decrease toward the periphery. On the outskirts of the area of greatest arteriosclerosis are a few white atrophic patches in the choroid, some of them with a pigmented border. We also see in this zone a few angular patches, consisting only of pigment, which are probably situ- ated in the retina. The retina is not diseased and the walls of its vessels show no changes. The experiments of Wagenmann have shown that disturb- ance of the nutrition of the choroid is followed also by atrophy and secondary pigmentation of the retina. d. D. Chor. Sklera f^^. ^-'^^iiV^- Oor. Tuherkel '•f^^j ^.^iV Chorioidea Corp. vitr. Retina ^ Sklera, V K. ^-^ Fig. 83. Fig. 82. a. Hyaline Bodies (Drusen) of the Vitreous Layer (cf. Fig. 72). — The hyaline structures, stained violet with hematoxylin, are seen upon the vitreous layer surrounded for the most part by the cells of the pigment-epithelium. The choroid is normal. The retina in this case was detached and is, therefore, not seen in the figure. Fig. 82, h. Miliary Tubercle of the Choroid (cf Fig. 75). — As the section is near the equator and parallel to it, most of the choroidal vessels appear in transverse section. At the center of the tubercle there are a few giant-cells, The retina is not shown in the drawing. In mounting the preparation the choroid became separated from the sclera and the interval is in part filled with the layers of the suprachoroidea. The patient died of miliary tuberculosis. Fig. 82, c. Large Tubercular Growth in the Choroid com- posed of Several Nodules : F, transverse section of a choroidal vessel ; K, caseous portion of the tubercle ; R.R., giant-cells. The three figures appear magnified 30 times. Fig. 83. Meridional Sections through Eyes with Choroidal Sarcoma, stained with hematoxylin and eosin (life-size). — In a there is between the retina and the tumor a layer of amorphous exudate similar to the exudate beneath the rest of the retina which is detached. In h the tumor, except for its posterior portion, is covered by the retina ; while in c the retina invests the entire surface of the tumor. In none of the three cases did the tumor break through the sclera. In d is shown the microscopic structure of a pigmented sarcoma of the choroid, which is seen to be composed princi- pally of spindle-shaped cells containing more or less pigment, though in places the pigment is entirely absent. Magnified 112 times. Fig. 83. p I r*-H •"'•CD tif' >-t br'CO « '-I ■< Hi.' a =^0 «^ 1 ,^ CuC^ ^ '^ o ^ ^ o cP (p^ ^ ^ a* ' g^ ^w "»^ "^^^ ^ ^ij X-o-2 Sioo - ^^ js H-. P-i j3-,_5 CTQ O „ S ti a:, H 33 S.^ •=S5"^^:^ HH»e^ ^ g CL P. a ^ ^ ^ ^ ^ -. c» tj, ^ g. rt>aji^iiM03j-f.C(p Hj oi ', ^^^^r^^lpv^gS^ocpg Fig. 85. True Staphyloma in a Highly Myopic Eye (first described by Weiss). — While the pale atrophic "sickles" or " menisci " at the temporal border of the papilla or the cir- cular atrophy of the choroid around the papilla when mod- erately large, practically never, and when quite large very rarely, show any staphylomatous bulging, and therefore have no just claim to this obsolete designation, this is not the case in a true staphyloma, such as we have represented here, which is usually met with only in high grades of myopia (above 20 D) and is accordingly uncommon. In this case we see, especially to the nasal side of the papilla, the distinct border of an excavation, and the blood- vessels as they pass over it are deflected. The edge of the excavation is recognized either by a more or less marked shadow or by a more or less distinct gray line running along the summit. The curve varies considerably in size, that is to say, it may form a greater or larger segment of a circle or of an oval. Occasionally- the edge of the staphyloma is cir- cular and surrounds the entire posterior pole, but even in such cases it is always most pronounced to the nasal side of the optic nerve. The edge of the staphyloma is best seen by parallactic dislocation, even when it is difficult to see it with the ophthalmoscope. Fig. 85 shows, in addition, three atrophic sickles near the papilla over which the vessels pass without undergoing deflec- tion. We also note that the course of the retinal vessels is characteristic of a high degree of myopia : the main trunks, instead of passing upward and downward, extend more to the temporal side. The posterior pole (macula and surroundings) shows a decrease and loosening of the pigmentation, which is also characteristic of a high degree of myopia. In this patient I removed the myopia of 30 D by an operation (dis- cission of the lens), and the eye became almost emmetropic with good vision. r \ V / / Fig. 85. HH p o o ji: o s ^ 1q o^ g ^ ^ ^pOp^^ po so crq ^ o • - <^ ^ D ^ ^ a oow*e?3 5'^ S ^ S- Cr- . •^ "5 ;i P CD era 2 ® ^ o ^ •3 ^ c» g 5 oo 5 o ?" c; o 5=>S- 3 o.^ "^ TO H-. -.* '^ !^- i? § l§ » CD CD ~^ Ci o "^ *^ o B CD g 3 TO —• o "xJ ST p TO «-.^ O Hj O P CD g e* p *^ PS 2 C ^ 5 ^ p p p CD CQ ^ < TO-'jO >— I -g^ ^-pI to o §•% § g p-^^.B 5^ cr a> < v; 5« (D crq P CD Hi ^<2 g (D cTS CD CD g P ^Crq - g cj; ^ ^ ^o-^_ o c S o p p CD C S I aq 2 TO ^ ^' O P CD ^ "IP-^TS _^. ^CDCJpOSLpr^ ori5: O B ' f^^oO P TO JT ^ ffLi B « TO B ° TO P- g ^^-:§ ^ 3 -. r^ 2. O j;^ C CD e^ BO^ Cf<5'^^co^3- q:^ o-o. ^2-0 o B c hr^o P P CD «r» o o c P- CD TO Fig. 87. Pupillometer. — Since it is quite easy in com- paring two eyes to estimate a difference of a few centimeters in the width of the two pupils, it would seem to be wise to adopt a similar method of measuring the pupil in daily prac- tice and to determine the width of the pupil by comparing it with a painted picture of a pupil. A number of black disks arranged in a perpendicular row are held near the eye and the disk corresponding to the pupil is then picked out. This method is sufficiently accurate for ordinary purposes, as I have found in my own practice. One of the strips on the opposite page should be cut out and attached to the millimeter measure which is used for measuring the pupillary distance in ordering glasses, or it may be pasted on a strip of cardboard. The two other strips will serve to renew this simple instrument. Tab. 87. • 1.5 • 2.0 3.0 3.5 4.0 4.5 5.0 6.0 6.5 7.0 • 1.5 • 2.0 • 2.5 3.0 3.5 4.0 A 4.5 5.0 6.0 6.5 18.0 7.5 8.0 • 1.5 • 2.0 • 2.5 % 3.0 • ..5 #4.0 #4.5 A 5.5 6.0 6.5 /.o 18.0 NDEX. Accommodation in direct method, 23 Air-bubble in vitreous, Fig. 56 Albinismus, Fig. 10, b Albuminuria, retina and optic nerve in. Figs. 25, 28, a Albuminuric disease of eve-ground, Fig. 28, h Anemia, pernicious, eye-ground in, Fig. 31 retina in, Fig. 67, a Anterior chamber, angle of, after glaucoma. Fig. 24, 6 Aortic insufficiency, arterial pulsa- tion and, 86 Arteria centralis retina^, 80 Arterial pulse, 82 aortic insufficiency and, 86 Arteries, 80 Astigmatism, 34 irregular, 37 measurement, 34 shadow-test for, 56 Atrophic menisci. Fig. 85 sickles. Fig. 85 Atrophv of choroid in mj^opia, Fig. 84 of optic nerve. Figs. 19, 58, I, b due to intra-ocular tension. Fig. 22 gray. Fig. 20 partial. Fig. 21, a total. Fig. 21, 6 of retinal vessels. Fig. 58, I, b Berlin's opacity, Figs. 51, 53 Blood-vessels, 80 Brain-tumor, inflammation of optic nerve in. Fig. 13 Central artery, obstruction of. Fig. 32 vein, thrombosis of, Fig. 33, 6 Choked disc. Figs. 13, 13, a, 15 Chorioretinitis^ Fig. 43 Choroid after contusions, Fig. 80 atrophy of, in myopia. Fig. 84 chronic tuberculosis of, Fig. 76 congenital defects of, Figs. 7-10 diseases of. Figs. 68-86 infiltration of, in disseminated choroiditis. Fig. 70 lacerations of. Fig. 80 miliary tubercles in, Figs. 75, 82, b phantom tumors of, Fig. 77 retina, and optic nerve, recent inflammation of. Fig. 73, a and sclera, .section through. Fig. 3 sarcoma of. Figs. 77, 78, 83 tubercular growth of. Fig. 82, c vitreous layer of, hvaliue bodies in. Figs. 72, a, 82, a Choroidal pigmentation, 76 ring, 76 vessels, .sclerosis of. Fig. 81 Choroiditis dis.seminata. Figs. 69, 73, 6 advanced case. Fig. 69 areas of infiltration in, Fig. 70 chronic, and pigmentation of retina, Figs. 43, 74, 81 early stage, Fig. 71 inflammatory focus in. Fig. 67, b recent, Figs. 68, 73, 79 postica. Figs. 44, 45 Cilioretinal vessel, 81 Coloboma choroideae. Fig. 7 et nervi optici, Fig. 8, a Color of eye-ground, 75 Colored illustrations in ophthal- moscopy, 15 Commotio retinae, Figs. 51, 52 Congenital defects. Figs. 7-11 Contusion of eyeball, perforation after, Fig. 49 90 INDEX. Contusions, choroid after, Fig. 80 r Corneal region, detection of opaci-^ ties in, by transmitted light, 47 Cylindrical lens, 36 Diabetes, eye-ground in. Fig. 30 Direct method, determination of inequalities by, 45 enlargement of image in, 43 mirrors in, 73 of examination, 22 size of field of vision in, 38 Dislocation of lens, congenital, Fig. 11 Displacement, parallactic, 46 Disseminated choroiditis. See Cho- roiditis. Donders on venous end-pulse, 84 Ectopia lentis congenita. Fig. 11 Embolism of superior temporal ar- tery. Fig. 34 Em met rope, examination by, 24 Emmetropic eve, direct examina- tion, 24, 27 examination in erect image, 27 Endarteritis, obliterating, of su- perior temporal artery, Fig. 34 >^ Erect image, examinations in, 23 Erect-image method of examina- tion, 22 Examination by indirect method, 40 bj^ transmitted light, 47 in erect image, 23 of eye-ground, 13 ophthalmoscopic, 67 first step, 68 fourth step, 72 second step, 69 third step, 69 Excavation, physiologic, 77 Ej'eball, contusion of, perforation of macula lutea after. Fig. 49 Eye-ground, albuminuric disease of, Fig. 28, h changes in, resulting from severe forceps deliverv. Fig. 58, I, a color, 75, 76 colored illustrations of, 15 examination, 13 illumination, 20 Eye-ground in congenital syphilis. Figs. 41, 42 in diabetes. Fig. 30 in hereditary syphilis. Fig. 40 in leukemia. Fig. 65 in pernicious anemia. Fig. 32 irregularities on, determination, 45 normal, 73; Fig. 1 blonde, Fig. 4 dark. Fig. 5 observation of, 22 point of impact of foreign body on. Fig. 58, a rules for observing, 32 Far point, 26 Field of vision, size of, in direct method, 38 in indirect method, 42 Flame, size of, ophthalmoscopic field and, 39 Flux, intermittent, 83 Foreign body in vitreous, Fig. 53 detection of, by transmitted light, 50 Foveal reflex, 79 Glaucoma, angle of anterior cham- ber after. Fig. 24, h atrophv of optic nerve from. Fig, 22"^ optic nerve in. Fig. 24, c, d Glaucomatous excavation of optic nerve. Fig. 23 Glioma of retina, Fig. 66 Haab's ophthalmoscope, 62 Heart-disease, arterial pulse and, 86 Helfreich on venous end-pulse, 84 Helmholtz's discs, 21 Hemorrhages into retina. Fig. 35 into vitreous. Fig. 35 Homocentric pencil, 34 Hyaline bodies in vitreous laver. Figs. 72, a, 82,_ a Hypermetrope, examination by, 25 Hj'permetropia, detection of, by transmitted light, 51 latent, 30 manifest, 30 total, 30 Hypermetropic eye, examination in erect image, 27 measurement, 29 INDEX. 91 Illumination of eye under exam- ination, 21 Image, enlargement of, in both methods, 43 Indirect method, advantages of, over direct method, 42 determination of inequaUties by, 46 enlargement of image in, 44 examination by, 40 measurement of refraction by, 45 size of field of vision in, 42 Inflammation of optic nerve. Fig. 12 in brain-tumor. Fig. 13 in orbital tumor. Fig. 18 in syphilis. Fig. 16 intense. Fig. 17 Intermittent flux, 83 Introduction, 13 Irregular astigmatism, 37 Jackson on shadow-test in astig- matism, 57 Jackson's ophthalmoscope, 65 Keratoconus, detection of, transmitted light, 52 Keratoscopy, 53 by Laceration in retinal detachment, Fig. 62 of choroid. Fig. 80 Latent hypermetropia, 30 Lens, congenital dislocation of, Fig. 11 convex, in ophthalmoscopes, 62 in shadow-test, choosing of, 5^ cylindrical, 36 detection of opacities of, by transmitted light, 48 Leukemia, eye-ground in, Fig. 65 Liebreich's ophthalmoscope, 66 Loring's ophthalmoscope, 63 Randall's modification, 65 Macula, 78 lutea, disease of, from age. Fig. 47 ' from blow. Fig. 48 from foreign body. Fig. 53 from myopia. Figs. 44, 45 from pressure and contusion, Fig. 54 Macula lutea, horizontal section of, Fig. 14 image in, 34 in disease from tumor. Fig. 50, a perforation of. Fig. 49, a strippling of eye-ground in, 79 reddish-brown spot in, 76 Macular disease, Fig. 58, I, b reflex, 78 Manifest hypermetropia, 30 Marginal reflex, 80 Marple's electric ophthalmoscope, 65 Medullated fibers of retina. Fig. 6 Menisci, atrophic. Fig. 85 Miliarv tubercles in choroid, Figs. ^75, 82, 6 Mirror, concave, for shadow-test, 56 Mirrors in direct method, 39, 74 Myope, examination by, 24 Myopia, atrophy of, choroid in. Fig. 84 detection of, bv transmitted light, 51 disease of macula lutea from. Figs. 44, 45 Myopic eye, measurement of, 26 true staphyloma in. Fig. 85 Nerve-fibers, medullated, in ret- ina, Fig. 6 varicose, in retinitis albuminu- rica. Fig. 26, 6, c Neuritic atrophy. Fig. 19 Neuritis, optic, Fig. 12, a and macular changes in tumor of cerebellum. Fig. 13, a section through papilla in. Fig. 15 Neuroretinitis albuminurica. Fig. 25 specific. Fig. 16 syphilitic. Fig. 37 Normal eye, section through angle of anterior chamber of. Fig. 24, a eye-ground, 74. See also Eye- qround. papilla, longitudinal section. Fig. 2 Obstruction of central artery, Fig- 32 of superior temporal artery, tig. 34 92 INDEX. Opacities in corneal region, detec- tion of, by transmitted light, 47 in refractive media, detection of, by transmitted light, 47 in vitreous, detection of, by transmitted light, 50 of lens, detection of, by trans- mitted light, 48 Ophthalmoscope, choice of, 58 convex lens, 62 description, 18, 58 Haab's, 62 Jackson's, 65 Liebreich's, 66 Loring's, 63 Randall's modification, 64 Marple's, 65 Ophthalmoscopic examination, 67 first step, 68 fourth step, 72 second step, 69 third step, 69 field of vision, size of, 38 Optic disc, 77 nerve, 77 and retina in albuminuria. Figs. 25, 28, a atrophy of. See Atrophy. choroid, and retina, recent in- flammation of. Fig. 73, a in orbital tumor. Fig. 18 diseases of. Figs. 12-24 glaucomatous excavation of, Fig. 23 in glaucoma. Fig. 24, c, d inflammation of. See Inflam- mation. left, viewing of, 70 malformation of, with congeni- tal choroidal defect. Fig. 8, a right, viewing of, 71 through ophthalmoscope, 76 neuritis and macular changes in tumor of cerebellum, Fig. 13, a Opticociliary vessel, 82 Orbital tumor, inflammation and congestion of nerve in. Fig. 18 Papilla, 77 normal, longitudinal section. Fig. 2 section through, in neuritis, Fig. 15 in papillitis, Fig. 15 Papillitis, Figs. 13, 15, 17 section through papilla in. Fig. 15 Parallactic displacement, 46 Pencil, homocentric, 35 Pernicious anemia, eye-ground in, Fig. 31 retina in. Fig. 67, a Phantom tumors of choroid. Fig. 77 Phenomena, pulsation, 82 Physiologic excavation, 77 Pigment, congenital absence of. Fig. 10, h Pigmentary degeneration of retina, Figs. 38, 39 Pigmentation, choroidal, 76 Pigment-epithelium of retina, con- genital defect of. Fig. 8, h Posterior veniB vorticosse, Fig. 86 Pregnancy, hemorrhagic retinitis of. Fig. 63 Pulsation j^henomena, 82 Pulse, arterial, 82, 87 venous, 84 Punctum remotum, 26 Pupil, cause of black appearance of, 18 Pupillometer, Fig. 87 Pupilloscoi^y, 53 Randall's modified Loring oph- thalmoscope, 65 Red coloration of normal eye, 75 Reflexes on retina, 77 Refracting power, measurement of, 23 system of eye, 18 Refraction, points to be observed, 33 Schmidt-Rimpler method of measuring, 45 Refractive media, detection of, opacities in, by transmitted light, 47 surface with greater curvature in vertical than in horizontal meridian, 35 Retina, 77 and optic nerve in albuminuria. Figs. 25, 28, a blood-vessels of, 80 choroid, and optic nerve, recent inflammation of. Fig. 73, a and sclera, section through, Fig. 3 glioma of, Fig. 66 INDEX, 93 Retina, hemorrahges into, Fig. 35 in pernicious anemia, Fig. 67, a in retinitis albuminurica, Figs. 26, 27, 29 in thrombosis of vena centralis retinae, Fig. 50, 6, c inflammation of, in syphilis, Fig. 16 injury of, from iron splinter. Figs. 55, a, h, 57 meduUated nerve-fibers in. Fig. 6 opacity of, from blow, Figs. 51, 52 pigment of congenital defect of. Fig. 9 pigmentary degeneration of, Figs. 38, 39, 46, c pigmentation of, choroiditis and, Fig. 81 disseminated choroiditis and. Fig. 74 secondary, Fig. 46, a in disseminated choroiditis. Fig. 43 senile. Fig. 72, h pigment-epithelium of, congeni- tal defect of, Fig. 8, 6 pulsation in, 82 reflexes on, 77 thrombosis of blood-vessels of. Fig. 33 Retinal arteries, syphilitic disease of. Fig. 36 bands and detachment. Fig. 60 from traumatism, Fig. 58, h detachment. Figs. 59, 61 and bands. Fig. 60 funnel-shaped. Fig. 46, h total. Fig. 46, 6 with laceration. Fig. 62 separation, detection of, by transmitted light, 52 vessels, atrophy of. Fig. 58, I, h Retinitis albuminurica. Figs. 26, 27, 29 of both eyes. Fig. 29 varicose nerve-fibers in. Fig. 26, h, c circinata. Fig. 64 diabetica. Fig. 30 hemorrhagic. Fig. 33, a of pregnancy, hemorrhagic. Fig. 63 pigmentosa. Figs. 38, 39, 46, c, d proliferans. Fig. 58, 6 Retinoscopy, 48 Rules for observing eye-ground, 32 Sarcoma of choroid, Figs. 77, 78, 83 Schmidt-Rimbler method of meas- uring refraction, 45 Sclera, retina, and choroid, section through. Fig. 3 Scleral ring, 76 Sclerosis of choroidal vessels, Fig. 81 Senile macular disease. Fig. 47 Shadow-test, 48 in astigmatism, 52 Sickles, atrophic, Fig. 85 Skiascopy, 53 in astigmatism, 56 Solutio retiniE, Fig. 62 Staphyloma, true. Fig. 85 Strippling of eye-ground in macula lutea, 79 Superior temporal artery, obstruc- tion of. Fig. 34 vein, thrombosis of, Fig. 33, a Syphilis, congenital, eye-ground in, Figs. 41, 42 hereditary, eye-ground in, Fig. 40 inflammation of optic nerve in, Fig. 16 of retina in. Fig. 16 Syphilitic disease of retinal arte- ries. Figs. 36, 37 neuroretinitis, Fig. 37 Temporal artery, superior, ob- struction of. Fig. 34 vein, superior, thrombosis of, Fig. 33, a Thrombosis of central vein. Fig. 33, h of superior temporal artery. Fig. 34 veiia. Fig. 33, a of vena centralis retina?, retina in, Fig. 50, 6, c Total hypermetropia, 30 Transmitted light, examination bv, 47 Traumatic macular disease. Fig. 48 Tubercle, miliary, in choroid. Figs. 75, 82, h Tubercular growth of choroid. Fig. 82, c Tuberculosis, acute miliary, of cho- roid. Fig. 75 chronic, of choroid, Fig. 76 Tumor, detection of, by transmitted light, 52 94 INDEX. Tumor, orbital, macula lutea in, Fig. 50, a phantom, of choroid, Fig. 77 Tiirk on venous end-pulse, 86 Veins, 80 vortex-, posterior, 82 Vena centralis retina?, 80 thrombosis of, retina in. Fig. 50, h, c Venae vorticosaj, posterior. Fig. 86 Venous pulse, 82, 83 Vision, field of, ophthalmoscopic, size of, 38 Vision, field of, size of, in direct method, 38 in indirect method, 42 Vitreous, air-bubble in. Fig. 56 connective tissue in, Fig. 58, I, 6 foreign body in, Fig. 53 detection of, by transmitted light, 50 hemorrhages into, Fig. 35 layer, hvaline bodies in. Figs. 72, a, 82, a opacities in,, detection of, by transmitted light, 50 Vortex-veins, posterior, 82 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. Form L9-Series 4939 f >'C^<^^^^