The optic nerve will have a pinkish appearance from contrast with the whiteness of the staphyloma, due to the sclerotic shining through the atrophied choroid. The retina is detached somewhat from the choroid and the retinal vessels may be seen passing across the staphyloma. Vision becomes affected by enlargement of the blind spot and there is usually some amblyopia, which may be due to the reflection of light from the white surface and to the congestion of the retina.
If the disease becomes progressive, the myopia increases, the vision is more and more impaired, the black spots before the eye increase and the optic nerve and retina become more irritable. The edges of the crescent show signs of inflammation, appear more irregular and congested; there is slight proliferation of pig-ment in small spots surrounding the borders of the staphyloma, which increases more and more as the disease advances and extending especially toward the macula. These spots of pigment gradually coalesce and the centres undergo a gradual change in color until they form one large, white, atrophic spot with a nar row border of pigment surrounding it, similar to the changes found in disseminated choroiditis.
CAUSES.-Posterior staphyloma is considered to be mechanical in its origin. The predisposing cause being congenital and hereditary, the insertion of the optic nerve being obliquely, and to the inner side of the posterior pole of the eye, would render the outer side where the staphyloma occurs weaker, and any abnormality in this direction would increase the weakness at that point. The exciting causes are first an insufficiency of the internal recti, causing a dragging upon the eye from prolonged effort of convergence, and results in an elongation from an increased pressure upon the eyeball. The use of the accommodation in myopic eyes is another factor in the causation of posterior staphyloma. In myopia the longitudinal fibres of the ciliary muscle are especially developed, and in the effort of accommodation there is a drawing forward of the choroid through the fibres of the tensor choroidea, which results in an increased vascularity of the choroid at its attachment around the optic nerve. In this way there is created a low form of choroiditis at that point which causes a softening and bulging of the tissue. The sclera is more vascular around the optic nerve, and any congestion there would serve to soften its tissue. An increased vascularity would tend to increase the tension, but owing to the weakness of the sclera, it bulges instead. Bending the head forward, as is so frequently seen in myopic children, seems to increase the vascularity and so increase the staphylom. Myopia is especially liable to increase from ten to twenty years of age, because at this time the sclera is more pliable and the child is using the eyes more.
COMPLICATIONS.-As a result of posterior staphyloma, we frequently find opacities of the vitreous and pigmentation of the retina from the traction upon it.
The majority of cases of detachment of the retina are dependent upon the posterior staphyloma. Posterior polar cataract is also apt to result from disturbances of nutrition.
PROGNOSIS.-The prognosis should always be guarded especially if the patient is obliged to use the eyes.
TREATMENT.-As myopia always accompanies this disorder of the fundus, the proper selection of glasses should receive our first attention, the greatest care being taken that they are not too strong. We should next warn the patient against the overuse of the eyes for near object, and also to always avoid stooping or bending forward when using the eyes at near work as this tends to increase the venous congestion, thus serving to accelerate the progress of the disease. It is injurious to read in the recumbent position. These patients should, therefore, sit upright, with head erect, when reading, and with the back to the light, so that the page will be illuminated and the eyes not subjected to its bright glare. The work or book should not be brought nearer as the eye becomes fatigued, but be laid aside until the eyes are thoroughly rested. If the patient complains of dazzling from the bright light, as is often the case, either blue or smoked glasses may be allowed. In aggravated cases they should be required to abstain from all near work. An effort should also be made to overcome the insufficiency of the internal recti by exercising with prisms as described under exophoria, as by increasing the power of convergence we remove somewhat the strain upon the accommodation.
The constant and continued use of Atropine for a long time has been found advantageous in some instances.
Belladonna.-Sclero-choroiditis posterior, with flushed face and throbbing congestive headaches. The eye appears hyperaemic externally as well as internally. The optic nerve and whole fundus are seen congested. Opacities may be present in the vitreous; photopsies and chromopsies are sometimes observed. The eyes quite sensitive to light.
Duboisia.-Vessels of the optic disc and retina much enlarged and tortuous. Disc congested and outlines indistinct. Sharp pain in the upper part of the eyeball.
Phosphorus.-Fundus hyperaemic. Muscae volitantes and flashes of light before the vision. Everything looks red.
Prunus spin.-Staphyloma posterior, accompanied by pains in ball, as if pressed asunder, or sharp and shooting in and around the eye. Vitreous hazy and vessels of the fundus injected.
Spigelia.-When accompanied by sharp stabbing pains through the eye and around it, often commencing at one point and then seeming to radiate in every direction.
Thuja.-An important remedy in all inflammatory conditions of the sclera, especially in strumous or syphilitic subjects. The globe may be quite sensitive to touch and the photophobia is usually marked.
Carbo-veg., Croc., Jaborandi., Lyco., Kali-iod., Mercurius, physos., Ruta and sulph. are also remedies to be borne in mind. Compare remedies for Choroiditis.
Senile Changes of the Choroid.-A rare form of colloid degeneration is sometimes met with in old people. There arises at the periphery from the lamina elastica, small, yellowish-white nodules which press forward into the retina, pushing aside the pigment layer. These nodules are irregularly scattered through the periphery and may be irregularly surrounded by pigment. They gradually extend toward the posterior pole of the eye. They resemble somewhat the spots of disseminate choroiditis, and are practically of little importance, as the vision is but very slightly, if any, disturbed.
Another form described by Berry (loc, cit.) as senile central choroiditis shows in the early stages a reddish-yellow, irregularly-oval shaped patch which later assumes more of an atrophic appearance the edges become more irregular and bordered by pigment. The patch generally appears in both eyes and varies in size. The condition causes metamorphopsia and a central scotoma, so that central vision is very greatly impaired. There is no tendency for the condition to extend to other parts of the fundus and hence visions is never entirely destroyed.
Albinism.-General absence of pigment in the tissues is a congenital defect which may affect the entire uveal tract. and when it does, the iris is of very pale blue, the pupil is small and there is a constant effort to avoid the light. Nystagmus is usually present, the lens may be ill-developed and there is always amblyopia. A pinkish glare is seen from the pupil, and with the ophthalmoscope the choroidal vessels are brilliantly outlined. Albinos always bring objects very close to the eyes to compensate for their amblyopia and to abate the nystagmus by strong convergence. Slight relief is obtained by the use of dark glasses to moderate the light.
Tumors of the Choroid.-Tuberculosis of the choroid occurs in the disseminated form or as a single nodule. The miliary form appears as small, round, elevated spots of a whitish or pale yellow color, which may within a few days grow larger and increase in number. Sometimes twenty or thirty may be counted in the eye. Both eyes may be involved, and they are especially found around the optic nerve. Pathologically they are the same as miliary tubercles elsewhere. With the addition that the giant cells contain pigment. The choroid between the nodules is hyperaemic and infiltrated with round cells. Their presence forms one of the symptoms of general miliary tuberculosis, especially when the meninges are affected.
Solitary tubercle of the choroid appears as a rather large light-colored tumor which causes detachment of the retina and blindness. They are found to consist of a great number of smaller miliary nodules that have coalesced. Their occurrence in young people and the discovery of other foci of tuberculosis are the diagnostic signs between the solitary tubercle and sarcoma of the choroid. As the eye is always lost and life endangered the prognosis is unfavorable. The treatment is enucleation.
Sarcoma.-Nearly all varieties of sarcoma may be found occurring in the choroid, although the pigmented or melano- sarcoma are by far the most frequent. Sarcomas usually commence at either the ciliary region or around the posterior pole of the eye. When located anteriorly the iris is apt to be bulged forward and upon dilatation of the pupil a greyish-brown or black mass may be seen and a scotoma is present. If in the macular region there is in the early stage loss in visual acuity and the ophthalmoscope shows a detachment of the retina of a nodular form and abrupt sides. The diagnosis of a tumor behind the detachment may present some difficulties. If a tumor is present, the color appears darker than in a simple detachment and the tension is increased; while, in simple detachment, the tension is diminished, the detached part of the retina has a wavy appearance on movement of the eye, generally occurs at the posterior pole of the eye and usually settles to the bottom. Glaucomatous symptoms in a detachment of the retina generally indicate the presence of a tumor. The origin of the growth in some cases may be traced to an injury of the eye, although more often it is primary condition with no traceable cause. Knapp A Treatise on Intra-ocular Tumors. divides the symptoms and progress of choroidal sarcoma into four stages: First, the origin and commencing growth without symptoms of pain or irritation of the eye, the only subjective symptom being a disturbance of vision. The first stage varies from six months to four years. Second, the appearance of inflammatory symptoms in the eyeball. The most characteristic symptom of this stage is the severe pain due to the increased tension. In this second, or glaucomatous stage, blindness rapidly comes on and the diagnosis is now often impossible. This stage usually lasts about one year. Third, the stage of perforation, when the external appearance of the growth, if it breaks anteriorly, is that of dark, hard nodules. If the perforation occurs at the posterior pole we soon get an exophthalmos and restricted movement of the eye. There is at first relief of pain, but as the progress is now rapid pain returns, haemorrhage and an abundant secretion sets in and there is simply a mass of tumor and death is apt to occur from exhaustion. The fourth and last stage is that of metastasis to other organs, usually the liver or lungs, with the inevitable death of the patient. Sarcomas occurring at the posterior pole of the eye, while rare, have been found, and Griffith Archiv. Ophthal., vol. xvii., 2, 1888. reports a case seen by himself and gives the records of six other cases. Sarcoma appears especially in old age, is very rarely seen under forty, and rarely affects but one eye. The prognosis is fatal if left alone and is unfavorable even in the early stage. There is but little danger of recurrence in the orbit after enucleation in the first stage, but Fuchs says the danger of metastasis is not essentially influenced by the time at which the operation is performed. The pigmented variety is more malignant and more liable to return, especially when it has reached the glaucomatous stage prior to removal. About two-thirds of all sarcomas return after removal. Microscopical examination may show the tumor to be any one of the following varieties: Melanosarcoma, leuco-sarcoma, myo-sarcoma, chondro-sarcoma, osteo-sarcoma, cysto-sarcoma, glio-sarcoma, or sarcoma- cavernosum. The treatment should always be an early enucleation and care should be taken to severe the optic nerve as far back as possible. In the third stage the orbit must be thoroughly cleaned out.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.